Which law does your health insurance plan follow?

After you identify what type of plan you have, you’ll need to identify who regulates that plan. This will determine your appeals process. Use the chart below to find out who regulates your plan.

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) (www.hhs.gov). 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 or agent

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

 

 

 

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

 

 

X

Medicare Advantage

 

 

X

Pre-Existing Condition Insurance Plan (PCIP)

 

 

X

Washington Apple Health

 

 

X

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

X

 

 

Note: If your plan isn’t subject to state or federal laws listed above, your plan may be allowed to establish its own process. Check with your plan regarding your appeals process.

Updated 11/07/2014

See also

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