Coverage not active

What it means

The plan’s records show no active coverage for you on the date of service. That can happen for several reasons: a premium was not paid and the coverage ended; your employer ended your enrollment after a job or hours change, or a form was missed; an enrollment window was missed; Medicaid ended; the plan cancelled the policy; or someone simply made a clerical mistake. Which one it is decides who can fix it and how fast you must move.

Who has to act first

You do. Start by finding out who made the decision: the plan, your employer, the Marketplace or the state Medicaid agency. Ask for the reason and the date in writing.

• Employer plan. Ask your employer’s benefits office for your enrollment record and your payroll deductions. An eligibility denial is still a denial you can appeal to the plan. You have at least 180 days after you receive the notice for a job-based plan (check the date on your notice, which controls).
• Marketplace plan. A decision by the Marketplace itself about eligibility or enrollment is appealed to the Marketplace, generally within 90 days of the eligibility notice. A plan’s own cancellation or claim denial is not. Those go to the plan and then to external review.
• Medicaid. The state must send written notice at least 10 days before it ends coverage, with limited exceptions, and must tell you how to ask for a fair hearing. The deadline is set by the state and cannot be more than 90 days from the date the notice was mailed.
• Children’s Health Insurance Program (CHIP). The notice must give the reasons and how to ask for review. Separate CHIP programs use an external review, not a Medicaid fair hearing. Your notice says which applies.

Arguments that work

• Proof of payment. Bank or card records show premium payment dates. Ask the plan for a one-time reinstatement if a payment was missed. The Arthritis Foundation suggests asking.
• Employer error. If payroll kept taking deductions, ask the employer to correct your enrollment and send the plan the corrected effective date.
• No proper notice. A plan may cancel coverage retroactively only for fraud or an intentional misrepresentation of a material fact, and only after at least 30 days’ advance written notice. A cancellation for unpaid premiums is not that kind of rescission, so ask which one the plan says it is.
• A Medicaid notice problem. Ask for a hearing before the date the coverage ends, so the state generally may not end your services until it decides, unless the only issue is a change in law or policy. If the date has passed, the state may reinstate if you ask within 10 days.
• A Marketplace decision. A winning decision can take effect from the date coverage would have started, at your option.
• Other coverage. If you had another plan on that date, ask the provider to bill it. See the guide on two plans and continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

Evidence to gather

• Your insurance card and enrollment confirmation (you).
• Dates of coverage from the plan (the plan).
• Proof of premium payments (your bank or card).
• Payroll stubs showing deductions (your employer).
• Any notice that coverage would end, with the date it was sent (you).
• A Marketplace or Medicaid eligibility notice (you).
• Your call log (you).

What to send

Send the request to whoever made the decision: a letter to the benefits office, an appeal to the plan, a Marketplace appeal, or a fair hearing request. State the date of service, the claim number, why you think coverage was active, and attach the proof. Ask for a written decision.

When this is not worth an appeal

If your coverage ended properly, with notice, for unpaid premiums, and the payment records agree, an appeal cannot restore it. Ask about reinstatement, other coverage you may qualify for, hospital financial assistance and a payment plan. A state Consumer Assistance Program or insurance department may help you sort out options.