Health Insurance Denial and Cancellation Appeal Rights Under the Affordable Care Act (ObamaCare)

Customers have appeal rights for the denial of health insurance claims, the cancellation of health plans, and marketplace decisions under the Affordable Care Act (ObamaCare). However, one must appeal within the proper timeframe.

Here are the most important things you need to know about health insurance appeals:

  • There are a bunch of rules that you might want to review. For example, rules for timeframes in which an insurer is required to notify you about a denied claim. We can’t cover everything here, additional information can be found at the official government website HealthCare.Gov.
  • You have the right to appeal the denial of a health insurance claim (whether the insurer won’t pay, won’t pay the full amount, or tries to charge you out of network). In other words, any claim that isn’t billed how you think it should be under the terms of your contract can be appealed. You have 180 days of receiving the notice that your claim was denied to appeal. See Claim Denial Appeals.
  • You have the right to appeal the cancellation of a marketplace health plan (rules can differ for Medicare, Medicaid, employer coverage, etc). For marketplace plans you have 90 days from the 1st of the month your bill was issued in to pay the bill (so a bill issued in May must be paid by July 31 for example). If it goes past 90 days then you lose your appeal rights. Despite losing you right, in most cases you can get your plan reinstated if you appeal ASAP and have a valid reason for not paying (so if your credit card was changed and you didn’t update it, and you try to appeal say 100 days after cancellation, they might be nice and reinstate you). See Grace Periods.
  • You have the right to appeal a Marketplace decision to dispute decisions about eligibility or tax credits or tax credits. See How to Appeal a Marketplace Decision.

In other words, the Affordable Care Act specifically ensured appeal rights as long as they are initiated within the proper time frame.

Here are some additional important notes about health insurance appeals:

  • You have the right to both an internal appeal and external review. Generally your first step should be an internal appeal, and then if that is denied you would utilize a third party review.
  • If you don’t pay your premium you lose coverage retroactively, then claims from that period can be denied, and you can’t appeal those claims.
  • You can do multiple appeals if needed.
  • Essentially every appeal has a window of opportunity, so all appeals should be done ASAP.
  • Sometimes a doctor or the provider you had the service done with can help you (they can help claims get approved).
  • You should always check with your doctor and insurer to make sure a service is covered in non-emergency situations so you can avoid having to appeal or so you can make the internal appeal process easier.