The appeals process is different for grandfathered and non-grandfathered plans.
- A grandfathered plan is a health insurance policy that was in place before the Affordable Care Act (ACA) was signed on March 23, 2010.
- Grandfathered plans are not required to offer an appeals process that complies with the new requirements of the ACA until they’ve made certain changes that cause them to lose their grandfathered status.
- Check your benefits booklet to find out if your plan is grandfathered.
What does the appeals process for a grandfathered plan look like?
You must file your appeal with your health plan (your health plan may provide a form for written appeals) within the timeframe your plan requires. This will either be listed on the adverse determination, explanation of benefits or in your plan summary.
Your plan's decision could come back in:
Type of appeal
72 hours or less
If it is urgent
With a grandfathered plan:
All plans allow their participants at least one opportunity to request that the insurer reconsider the denial; some allow for more opportunities. If you have a grandfathered plan, you may or may not have the option to request an external review by a certified independent reviewer. Your plan is required to tell you if this option is available to you.
- If you lose the first level of appeal, you may have more internal levels to complete before you get a plan’s final decision on your internal appeal.
- Once you’ve completed all the internal levels, you might have the option to request an external review. If so, your health plan will assign an Independent Review Organization (IRO) to review your appeal. [RCW 48.43.535 and RCW 48.43.537 (leg.wa.gov)]
- The IRO must notify you and your health plan of a decision within the timeframe allowed (leg.wa.gov).
- If the IRO overturns the denial, the decision is binding to the health plan. If it upholds the denial, your only option at this point is to seek legal counsel and see if judicial review is available to you.
- Now that you know what the appeals process for a grandfathered plan looks like, learn how to appeal a health insurance denial.