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.
What this plan type is
An ACA Marketplace plan is a health insurance plan sold through Healthcare.gov or a state-based ACA exchange. Plans are certified Qualified Health Plans (QHPs) meeting Essential Health Benefit (EHB) requirements, actuarial-value bronze/silver/gold/platinum tiers, and consumer-protection standards. Eligibility for premium tax credits is based on income relative to the Federal Poverty Level.
Your appeal rights
ACA Marketplace plans are subject to the full ACA appeal-rights stack: ACA §2719 (internal + external review), ACA §2713 (preventive at $0 cost-sharing), ACA §2711 (no annual/lifetime limits on EHBs), ACA §1557 (nondiscrimination), MHPAEA. Internal appeal: 180 days to file, 30/60 days for plan decision, 72 hours for urgent. External review: 4 months to file, 45 days for IRO decision, 72 hours for expedited. ACA §1557 complaints go to HHS OCR.
Common denial patterns
- Medical-necessity denial
- Non-formulary drug
- Out-of-network reduction (NSA + state IDR may apply)
- Prior auth absent
- Failed-first step therapy
What's unique about this plan type
- STATE insurance commissioner CAN regulate — file complaints there in addition to federal HHS
- Premium tax credit reconciliation at year-end (Form 1095-A)
- Special Enrollment Period for qualifying life events
- Risk-adjustment + reinsurance + cost-sharing reduction subsidies for silver-tier members at ≤250% FPL
Frequently asked questions
What is a ACA Marketplace (individual / family) plan?
An ACA Marketplace plan is a health insurance plan sold through Healthcare.gov or a state-based ACA exchange. Plans are certified Qualified Health Plans (QHPs) meeting Essential Health Benefit (EHB) requirements, actuarial-value bronze/silver/gold/platinum tiers, and consumer-protection standards. Eligibility for premium tax credits is based on income relative to the Federal Poverty Level.
What appeal rights does a ACA Marketplace (individual / family) plan member have?
ACA Marketplace plans are subject to the full ACA appeal-rights stack: ACA §2719 (internal + external review), ACA §2713 (preventive at $0 cost-sharing), ACA §2711 (no annual/lifetime limits on EHBs), ACA §1557 (nondiscrimination), MHPAEA. Internal appeal: 180 days to file, 30/60 days for plan decision, 72 hours for urgent. External review: 4 months to file, 45 days for IRO decision, 72 hours for expedited. ACA §1557 complaints go to HHS OCR.
What's unique about a ACA Marketplace (individual / family) plan?
STATE insurance commissioner CAN regulate — file complaints there in addition to federal HHS Premium tax credit reconciliation at year-end (Form 1095-A) Special Enrollment Period for qualifying life events Risk-adjustment + reinsurance + cost-sharing reduction subsidies for silver-tier members at ≤250% FPL
Other plan types
- ACA §2719Internal + external review
- ACA §2713Preventive services at $0 cost-sharing
- ACA §2711No dollar limits on EHBs
- ACA §1557Nondiscrimination
- NSABalance-billing protections
- MHPAEAMental health parity
- Employer-sponsored fully-insured planAbout 35% of employer-covered Americans are on fully-insured employer plans — the employer pays prem
- ERISA self-funded employer planAbout 65% of employer-covered Americans are on a self-funded ERISA plan. The employer (or a TPA) bea
Sources
Appeal a ACA Marketplace (individual / family) plan denial
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