Appealing a decline in coverage

Your Benefit Appeal Rights Under the Affordable Care Act

If your health plan was created after March 23, 2010, the Affordable Care Act ensures your right to appeal, or to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules, now in effect, govern how your plan itself must handle your initial appeal. If your plan upholds its decision after its internal review, the law permits you to appeal to an independent reviewer who does not work for your health plan.

What This Means for You

• When an insurance plan denies payment for a treatment or service, you can appeal to the plan to review its own decision. Your plan must explain how to appeal when it informs you of the denial.

• When you appeal, your plan must give you its decision within:
  • 72 hours for denials of urgent care.
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of service you have already received. 

• If the plan still denies your request, it must explain why and tell you how to appeal for an independent review of the decision. In some cases involving urgent care, you may be able to have the internal and external review take place at the same time.

• If you do not speak English, you may be entitled to receive all appeals-related information in your native language.

Some Important Details

• The appeals provision applies to all health plans created or purchased after March 23, 2010  and affects each plan as that plan starts a new “plan year” or “policy year” on or after September 23, 2010.
• How much the law will change your appeal rights depends on the State you live in and the type of plan you have.  
• Some employers’ plans may have more than one internal review before you’re allowed to seek an external review.
• If you have questions about whether the appeals provision applies to you, ask your health plan orState insurance regulator. Your State may also have a health care consumer assistance program that can help.

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Jordan