ACA / Marketplace Plans: your appeal rights
ACA plans owe you 180 days to appeal, continued coverage during the fight, and a binding outside review at the end of it.
Is this you? You bought your plan on healthcare.gov or a state exchange, or you have an individual (non-employer) plan regulated by the Affordable Care Act.
The escalation ladder
Your specific 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.
Under the 2026 prior-authorization rules, impacted payers must give a specific reason for a prior-auth denial — not boilerplate. Ask for the exact criteria used, the guideline relied on, and the credentials of the reviewer. Vague denials are appealable on process alone.
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.
What to include in your appeal
- The Explanation of Benefits and denial letter
- Your plan's Evidence of Coverage, with the cited exclusion or criterion
- Physician letter of medical necessity
- For experimental denials: FDA status, guidelines, other insurers' coverage policies