Information on How to Report Problems

How do I Appeal My Insurance Company’s Decision?

If your health insurance has decided not to pay for something, you can appeal their decision. Under the ACA, you have a right to appeal the decisions of private health plans. The ACA also requires private health plans to let you know:

This does not apply to grandfathered health plans.

For step-by-step instructions on how to file an appeal, go to the HealthCare.gov’s website: https://www.healthcare.gov/how-do-i-appeal-a-health-insurance-companys-decision/

Can I Appeal a Decision from the Health Insurance Marketplace?

The Health Insurance Marketplace was created by the Affordable Care Act as a way for people to buy health insurance. The Marketplace will also tell you if you qualify for help paying for insurance, or if you qualify for Medicaid or the Children’s Health Insurance Program (CHIP). For more information about the Marketplace, click here.

If you don’t agree with a decision made by the Marketplace, you have a right to appeal it. You can appeal the following Marketplace decisions:

When you apply for insurance in the Marketplace, you’ll get a letter that tells you what you qualify for. It will also tell you how to appeal the Marketplace decisions.

For more information about how to appeal Marketplace decisions, go to the HealthCare.gov’s website: https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/

What Do I Do if My Employer or Insurance Company is Not Following the ACA?

The Affordable Care Act contains many requirements for insurance companies and employers.

If your employer or insurance company is not following the ACA, you can report them to the Department of Labor’s Occupational Safety and Health Administration. A fact sheet explaining how to report ACA violations can be found here: http://www.osha.gov/Publications/whistleblower/OSHAFS-3641.pdf

The ACA protects people who report violations. This is called whistleblower protections. This means that insurance companies and employers cannot stop a person’s health insurance, fire a person, or retaliate against people who report violations.

To view the Department of Labor’s interim rule about reporting violations, go to: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=23585

Where Can I Go for More Help?

If you need more help appealing your insurance company’s decisions, you can contact your state’s Insurance Commissioner. You can find your commissioner at this website: http://www.patientadvocate.org/index.php?p=178

Most states have navigators or assistors who will help people learn how to use the Marketplace. They can also help you appeal Marketplace decisions. To find a navigator or assistor in your state, go to: https://localhelp.healthcare.gov/