ACA / Marketplace Plans: your appeal rights

Marketplace and other ACA-regulated plans must give you 180 days to appeal, tell you exactly why you were denied, and keep covering an ongoing treatment while your appeal is pending.

After the internal appeal — or at the same time, for urgent cases — you can demand review by an independent organization with no ties to your insurer. Their decision binds the plan. Depending on your state this runs through the state insurance department or the federal HHS process.

ACA-regulated plans must run a formulary exception process: you, your representative, or your prescriber can request coverage of a clinically appropriate drug that isn't on the formulary. Standard requests must be decided within 72 hours; if your health is in serious jeopardy or you're already stable on the non-formulary drug, an expedited request must be decided within 24 hours. If the plan says no, you can take the exception itself to an independent review organization on the same clocks. A granted exception counts as an essential health benefit, and your cost sharing counts toward your annual out-of-pocket limit.

Under the 2026 CMS prior-authorization rule (CMS-0057-F), impacted payers — Medicare Advantage plans, Medicaid and CHIP (fee-for-service and managed care), and Qualified Health Plans on the federal Marketplace — must give a specific reason for a prior-authorization denial, not boilerplate. Ask for the exact criteria used, the guideline relied on, and the reviewer's credentials. A vague, non-specific denial gives you strong grounds to challenge the decision. (This rule does not reach most commercial or self-funded employer/ERISA plans.)

Insurers must cover emergency care based on your symptoms at the time — not the final diagnosis. If a reasonable person would have thought it was an emergency, it must be covered as one, in or out of network, with no prior authorization required.

For emergency care and for out-of-network providers working at in-network facilities, you can only be billed your in-network cost sharing. Balance bills in those situations are illegal — dispute them rather than paying. (Ground ambulance bills are not covered by these protections.)