US health-plan types
Each US health-plan type has its own appeal-rights framework, regulations, and complaint pathway. Find yours below.
ACA Marketplace (individual / family) plan
Individual and family plans purchased through Healthcare.gov or a state-based exchange. Appeal rights are the strongest available to commercial-plan members: ACA §2719 internal + external review + every essential health benefit protection.
Employer-sponsored fully-insured plan
About 35% of employer-covered Americans are on fully-insured employer plans — the employer pays premiums to a carrier that bears the claim risk. Appeal rights stack ERISA §503 + state insurance law + ACA §2719 + NSA.
ERISA self-funded employer plan
About 65% of employer-covered Americans are on a self-funded ERISA plan. The employer (or a TPA) bears the claim risk; an insurance carrier may only administer benefits. Appeal rights flow from ERISA §503.
FEHB (federal employees + retirees)
The Federal Employees Health Benefits Program covers ~8 million federal employees, retirees, and dependents. Plans are private carrier contracts administered by OPM, with appeal rights under 5 CFR Part 890 layered over standard ERISA/ACA-like internal review.
Medicaid managed care (MCO)
Medicaid managed care plans cover ~80 million Americans. Appeals follow 42 CFR Part 438 Subpart F and add the unique RIGHT-TO-CONTINUE-BENEFITS protection — services authorised before the denial must continue at the prior level during appeal.
Medicare Advantage (Part C)
Medicare Advantage plans are private Part C plans that replace Original Medicare. They have the strongest appeal-rights framework in US health insurance: 5 levels of appeal, expedited 72-hour decisions, and binding Independent Review Entity review.
Original Medicare (Parts A + B)
Original Medicare is the federal fee-for-service program covering inpatient (Part A) and outpatient (Part B) care for Americans 65+ or with qualifying disability. Appeal rights follow a separate 5-level track from MA.
TRICARE (military and dependents)
TRICARE covers active duty service members, retirees, and their families. Appeals are governed by 32 CFR §199.10 with TRICARE-specific timelines and a tiered review pathway through the contractor, the Defense Health Agency, and (in some cases) the courts.
Contact: hello@denialhelp.com