Identify your type of insurance coverage

Different plans have different regulators. It is important to determine who regulates your plan so you know your rights and which laws your plan's appeal process follows.

Your plan's appeal process is regulated by one of the folowing:

  • Federal laws (such as ERISA, COBRA, and HIPAA); and/or
  • Washington state law (Revised Code of Washington (RCW) and Washington Administrative Code (WAC) or
  • Neither - your plan may be allowed to establish its own process becuase it isn't subject to the federal or stte laws listed above.

Which law does your plan follow?

Use the chart below to find out who regulates your plan. This will determine your appeals process.

If your plan is in one of the first two columns and it’s a non-grandfathered plan, then it’s subject to the Affordable Care Act (ACA). If your plan is ACA-exempt, then it's a grandfathered plan.

    Type of health insurance Plan is regulated by:
    Washington state Federal Plan specific

     

    Subject to ACA

    (non-grandfathered)

    ACA Exempt

    Individual plan

     

     

     

    Insurance plans you buy from an insurance company, agent, or through the Washington Healthplanfinder.

    X    

    Washington State Health Insurance Pool (WSHIP)

       

    X

    Group plan (You buy through work or an association)

    Note: Double check with your human resource dept. to clarify which type of policy your plan is.

     

     

     

    Self-funded

     

    X

     

    Exempt self-funded or non-Employee Retirement Income Security Act (ERISA)

     

     

    X

    Fully insured

    X

     

     

    Other health plans including government sponsored

     

     

     

    APPLE Health (Medicaid for kids and adults)     X

    Basic Health Plan/Washington Health Plan

    X

     

     

    Original Medicare (Parts A and B) and Medicare prescription drug coverage (Part D)

     

     

    X

    Medicare Advantage

     

     

    X

    Pre-Existing Condition Insurance Plan (PCIP)

     

     

    X

    Dept. of Social and Health Services and Health Services Medicaid (Provider One)

    X

     

     

    Washington Health Insurance Plan

    X

     

     

 

What type of policies are not recognized as health plans?

If you have any of the policies listed below, contact your insurance company to learn what appeal process might be available to you, since these policies are not recognized as health plans by Washington state law (www.apps.leg.wa.gov).

  • Long-term care insurance
  • Medicare supplemental coverage
  • Limited health care services
  • Disability-income insurance
  • Coverage provided from an auto or homeowner personal injury claim
  • Worker's compensation coverage
  • Accident-only coverage
  • Employer-sponsored self-funded health plans
  • Fixed-payment indemnity or mini-med insurance
  • Critical illness coverage (a policy for serious illness, like cancer)
  • Dental only and vision only coverage
  • Short-term limited purpose insurance (for example, student coverage)


Updated 03/27/2014

See also

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