Federal regulations for insurance appeals
The appeal-rights statutes and coverage regulations DenialHelp cites in every appeal letter. Each page shows what the law requires, when to invoke it in an appeal, key deadlines, and source citations.
Medicare Advantage Grievances, Organization Determinations, and Appeals
The Medicare Advantage appeal track. MA enrollees have FIVE levels of appeal (vs the 2 levels typical of commercial plans) and significantly tighter deadlines, especially for expedited cases.
Medicaid Managed Care Grievance and Appeal System
The federal floor for Medicaid managed care appeals. Beneficiaries get internal plan appeal + State Fair Hearing rights, with expedited timelines for urgent care.
Affordable Care Act §1557 — Nondiscrimination in Health Programs and Activities
ACA §1557 prohibits discrimination in health programs and activities on the basis of race, color, national origin, sex (including sexual orientation and gender identity), age, or disability. Applies to any covered entity receiving federal financial assistance.
Public Health Service Act §2711 — Prohibition on Lifetime or Annual Limits
ACA §2711 prohibits lifetime AND annual dollar limits on Essential Health Benefits. Plans that try to enforce a 'visit cap' that functions as a dollar cap, or that re-categorise an essential benefit to dodge the rule, are non-compliant.
Public Health Service Act §2713 — Coverage of Preventive Health Services
ACA §2713 requires non-grandfathered plans to cover specified preventive services with ZERO cost-sharing — no deductible, no copay, no coinsurance. Plans frequently apply cost-sharing in error or when a preventive screening is recoded as diagnostic.
Public Health Service Act §2719 — Internal and External Appeal Processes
ACA §2719 guarantees every non-grandfathered group + individual health plan a standardised internal appeal AND an independent external review when internal appeal is upheld.
Employee Retirement Income Security Act §503 — Claims Procedure
ERISA §503 is the foundational federal appeal-rights statute for the ~135 million Americans on employer-sponsored health plans. The implementing reg at 29 CFR §2560.503-1 is the most-cited regulation in DenialHelp appeal letters.
Social Security Act §1115 Demonstration Waivers
§1115 waivers let states test Medicaid policy variations — including expanding eligibility, adjusting benefits, or imposing requirements that wouldn't be allowed under standard Medicaid. The current state's §1115 waiver may extend or restrict benefits relative to federal minimums.
Mental Health Parity and Addiction Equity Act
MHPAEA prohibits health plans from imposing stricter limits on mental health and substance use disorder benefits than they impose on medical/surgical benefits — applies to both financial limits AND non-quantitative treatment limitations (prior auth, fail-first, network adequacy, medical-necessity criteria).
Public Health Service Act §2799A — No Surprises Act balance-billing protections + Independent Dispute Resolution
The No Surprises Act (effective 2022) bans most out-of-network surprise bills for emergency care, air ambulance, and out-of-network providers at in-network facilities. It also created a Federal Independent Dispute Resolution (IDR) process between providers and payers.
Prudent Layperson Standard for Emergency Services Coverage
The Prudent Layperson Standard governs emergency-service coverage. The question is not whether the diagnosis turned out to be emergent — it's whether a prudent layperson would have presented to emergency care given the symptoms.
Transparency in Coverage Final Rule
The TiC rule requires non-grandfathered plans to publish machine-readable files showing in-network rates, out-of-network historical allowed amounts, and prescription drug rates. It also requires a self-service tool letting members see personalised cost-sharing.
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