Coverage type · Student, short-term or other
Student health plan
A health plan sold to students through a college or university. If an insurance company sells it, federal individual-market appeal rules apply and your state insurance department regulates the insurer. A plan the school funds itself is less clear.
On this page 7
- Who has this
- Students and their families who are covered by a plan offered through a college or university, whether they signed up themselves or the school enrolled them with their fees.
- Who regulates it
- If an insurance company sells the plan: your state insurance department regulates the insurer. If the school funds the plan itself: we could not confirm the regulator; ask the plan and your state insurance department.
- Can your state help?
- Partly. Yes if an insurance company sells the plan, because the state regulates the insurer and takes complaints. For a plan the school funds itself, federal rules were not confirmed and the plan is left largely to state law, so ask your state insurance department whether it can help. Find your state.
How to tell this is your coverage
- Look at your card and policy. If an insurance company's name appears as the insurer of the student plan, the plan is sold by an insurer and the rules below apply.
- Ask the school's student health insurance office, in writing: Is this plan insured by an insurance company, or does the school pay claims itself? Who decides appeals?
- Read the plan booklet's section on claims and appeals, and keep a copy. If it says the school or a claims administrator pays claims from school funds, treat it as a school-funded plan; we did not confirm the federal rules for those, so ask the plan and your state insurance department.
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 147.145, student health insurance coverage treated as 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 this kind of policy, 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.
- Your school's student health insurance office
Can tell you who insures the plan and how claims and appeals are handled. It cannot replace your state insurance department, and it is not an independent reviewer.
- 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 your coverage is a student health plan offered through a college or university. Student health insurance that an insurance company sells through a school is treated as individual health insurance coverage, with a few listed exemptions, and none of them is an exemption from the appeals rule. So the same federal appeal and external review rules apply as for other individual plans that are not grandfathered.
How to tell this is your coverage
Your card, your enrollment through the school and the plan booklet should name the plan. Ask the school’s student health insurance office who the insurer is and whether the school pays claims itself. Keep the reply.
What does not apply to you
The federal law for employer plans, the Employee Retirement Income Security Act (ERISA), does not apply, and neither does the Department of Labor’s help line for employer plans. If the school funds the plan itself, the federal individual-market appeal rules may not apply; we did not confirm what applies, so rely on your plan booklet and your state insurance department.
Where people go wrong
- Counting the appeal deadline from the wrong date. It runs from when you receive the denial notice. Check the date on your notice, which controls.
- Assuming the school plan is a short-term plan. Check the booklet; see the page for short-term plans and other non-compliant products.
- 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.
Sources
- 45 CFR 147.145, student health insurance coverage
- 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