Coverage type · Marketplace or individual plan
Individual plan bought outside the Marketplace
You bought a plan straight from an insurer or through an agent, not through the Marketplace. If it is not grandfathered, your insurer decides one internal appeal, then independent review, and your state insurance department regulates the insurer.
On this page 7
- Who has this
- People who bought an individual or family health policy directly from an insurance company or through an agent or broker, outside HealthCare.gov and state marketplaces.
- Who regulates it
- Your state insurance department is the main regulator of the insurer. The federal Department of Health and Human Services (HHS) steps in only if a state fails to substantially enforce the federal requirements.
- Can your state help?
- Yes. Your state insurance department regulates the insurer, takes complaints and, in 45 states and the District of Columbia (Centers for Medicare & Medicaid Services list as shown on 11 November 2026), runs or oversees the external review process. HealthCare.gov also points people to the state Consumer Assistance Program, which can file an appeal for you. These rules apply to individual policies that are not grandfathered. Find your state.
How to tell this is your coverage
- You paid an insurer directly, or an agent or broker enrolled you in a policy, and you did not choose the plan on HealthCare.gov or your state's marketplace website.
- Your policy and insurance card show an insurer's name, a plan name and a member number.
- Check that it is a full health insurance policy and not a short-term plan, a sharing ministry membership or a fixed indemnity product. Those have far fewer protections; see the page for short-term plans and other non-compliant products. A short-term policy usually says it is short-term and, under the federal definition, should carry a warning notice, but the federal agencies said on 7 August 2025 that they will not prioritize enforcing that definition.
- Check whether the policy says it is grandfathered (in place on 23 March 2010 and not changed in disqualifying ways). A grandfathered plan must say so in any summary of benefits it gives you, with contact details.
- If you are unsure, call the insurer and ask in writing: Is this an individual market policy? Is it grandfathered?
The appeal steps, in order
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Appeal to your insurer
Official name: Internal appeal (an appeal of an adverse benefit determination)
- Who decides
- Your insurer. Individual coverage must provide only one level of internal appeal before a final decision. The reviewer must be someone who did not make the first decision and must not defer to it.
- Your deadline
- At least 180 days after you receive the denial notice. Your plan may allow more time, never less. Check the date on your notice, which controls.
- Their deadline
- Urgent care: as soon as possible and no later than 72 hours after your appeal is received. Care you need approved first: 30 days. Care you already received: 60 days. HealthCare.gov's appeals page says a decision comes within 4 business days; the rule's limit for an urgent appeal is 72 hours, so use 72 hours. Check the date on your notice, which controls.
- What to send
- A written appeal naming the claim and the denial, with your records, your doctor's letter and your reasons. Ask first for your claim file, which the insurer must give you free. Before a final internal denial, the insurer must give you free any new evidence or reasons it used, early enough for you to answer. There is no fee to appeal.
- Form
- HealthCare.gov, internal appeals
- If you lose, or hear nothing
- If the insurer upholds the denial, request external review. If the insurer misses the appeal rules, you may go straight to external review.
- The rule
- 45 CFR 147.136(b), internal claims and appeals for individual coverage
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Independent external review
Official name: External review by an independent review organization (IRO)
- Who decides
- An independent review organization (IRO). If your state has a qualifying process, the state process applies and the IRO is assigned by the state or another independent body, never chosen by the insurer or you. In Alabama, Florida, Georgia, Texas and Wisconsin, as listed by the Centers for Medicare & Medicaid Services (CMS) on 11 November 2026, the insurer uses a private accredited IRO or the federal government's process, which is free and run by a contractor.
- Your deadline
- At least 4 months after you receive the denial notice (the final internal denial, if you appealed first). Your state may allow longer. Check the date on your notice, which controls.
- Their deadline
- A standard decision is due within 45 days after the IRO receives your request. An urgent decision is due as fast as your medical situation requires and no later than 72 hours.
- What to send
- Follow the instructions in your final denial notice. Include the denial notice, your records and your doctor's letter. Denials involving medical judgment, No Surprises Act protections or a cancellation of coverage (rescission) qualify. A state may keep a filing fee only if state law allowed it as of 18 November 2015: it may not exceed $25, must be refunded if you win, must be waived for hardship, and may not exceed $75 per person per plan year. The federal government's process costs you nothing, and its information line is 1-888-866-6205 (as of November 2026; confirm on the Centers for Medicare & Medicaid Services external review page).
- Form
- HealthCare.gov, external review
- If you lose, or hear nothing
- If the IRO overturns the denial, the insurer must provide coverage or payment immediately, even if it plans to go to court. The decision binds the insurer and you, except where other remedies exist under state or federal law.
- The rule
- 45 CFR 147.136(c) and (d), external review
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Complaint to your state insurance department
Official name: Regulator complaint
- Who decides
- Your state insurance department. It can look into whether the insurer followed the rules. A state Consumer Assistance Program can also help and can file an appeal for you.
- Your deadline
- We could not confirm a deadline for this step. A complaint does not stop your appeal or external review deadlines, so keep them running. Check the date on your notice, which controls.
- Their deadline
- Set by your state. We did not confirm a federal response time.
- What to send
- A short written complaint with your member number, the denial notice and the dates of every appeal.
- Form
- Find your state insurance department (National Association of Insurance Commissioners)
- If you lose, or hear nothing
- Use what the department tells you in your external review request or a lawsuit.
- The rule
- HealthCare.gov, internal appeals
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Lawsuit in court
Official name: State-law claim (ERISA does not apply)
- Who decides
- A judge. The federal employer-plan law (the Employee Retirement Income Security Act, ERISA) does not apply to a policy you bought yourself, so state-law claims such as breach of contract or insurance bad faith may be available. Which claims exist depends on your state's law, and we did not check it.
- Your deadline
- Set by your state's law and your policy. Ask a lawyer early. Check the date on your notice, which controls.
- Their deadline
- Set by the court.
- What to send
- A lawyer files the claim. Keep your whole appeal and external review record.
- If you lose, or hear nothing
- Free legal aid or a lawyer who handles insurance disputes in your state can tell you which claims you have.
- The rule
- ERISA section 4(b), 29 U.S.C. 1003
If waiting could harm your health
If waiting could seriously harm your health, ask your insurer for an urgent appeal. It must decide within 72 hours. If a doctor who knows your condition says the claim is urgent, the insurer must treat it as urgent. You can ask for an urgent independent review at the same time as the urgent appeal.
Free help for this coverage
- Your state Consumer Assistance Program
HealthCare.gov says these programs can help you appeal, and can file an appeal for you. The Centers for Medicare & Medicaid Services (CMS) list gives contacts by state, organized by type of coverage. It says no program receives federal grant money as of its September 2024 update, so confirm your state's listing is current.
- Your state insurance department
Answers questions and takes complaints about insurers and their policies. Find yours in the National Association of Insurance Commissioners directory.
- Federal external review information line
For states that use the federal government's process: 1-888-866-6205 (as of November 2026; confirm on the Centers for Medicare & Medicaid Services external review page). The process is free.
- Patient Advocate Foundation case management
Free one-on-one help for patients who qualify, by phone at 1-800-532-5274, Monday to Friday, 8:30 a.m. to 5:00 p.m. Eastern (hours as listed in November 2026). It has limits on how many people it can take each day.
Who this covers
This page is for you if you bought your own policy from an insurer, outside the Marketplace. Your insurer runs the plan, pays the claims and decides appeals about them. If the policy is a full, non-grandfathered health insurance policy, the same federal appeal and external review rules apply as for a Marketplace plan.
How to tell this is your coverage
Look at where you enrolled and what your policy says. If you enrolled on HealthCare.gov or a state marketplace, read the page for Marketplace plans instead. If the policy says short-term, or you pay a ministry, read the page for short-term plans and other non-compliant products.
What does not apply to you
The federal law for employer plans, the Employee Retirement Income Security Act (ERISA), does not apply to a policy you bought yourself, and neither does the Department of Labor’s help line for employer plans. Marketplace eligibility appeals do not apply either, because the Marketplace did not enroll you. If your policy is grandfathered, the general external review right does not apply, except for surprise-billing denials; see grandfathered plans.
Where people go wrong
- Assuming a plan sold by an agent is a full health insurance policy. Check for short-term or ministry wording.
- Assuming a call to the Marketplace can help with a claim denial. It cannot.
- Skipping the internal appeal. You generally must finish it before independent review unless you qualify for an urgent review or the insurer broke the appeal rules.
- Missing the external review deadline because you counted from the wrong date. It runs from the denial notice, at least 4 months.
Sources
- 45 CFR 147.136, internal claims and appeals and external review
- 42 U.S.C. 300gg-19, appeals process
- HealthCare.gov, internal appeals
- HealthCare.gov, external review
- Which states use which external review process
- HHS-administered federal external review process
- Consumer Assistance Program
- ERISA section 4(b), 29 U.S.C. 1003
- State insurance departments directory
- Patient Advocate Foundation case management