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 following:
- Federal laws (such as ERISA, COBRA and HIPAA)
- Washington state law - Revised Code of Washington (RCW) and Washington Administrative Code (WAC)
- Neither - your plan may be allowed to establish its own process because it isn't subject to the federal or state 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) (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/subject to ACA (non-grandfathered) | Plan is regulated by federal government/ subject to ACA (non-grandfathered) | Plan specific/ACA exempt |
|---|---|---|---|
Individual plan: Insurance plan you buy from an insurance company, agent or through the Washington Healthplanfinder | X |
|
|
Individual plan: Washington State Health Insurance Pool (WSHIP) |
|
| X |
Group plan* (you buy through work or an association): Self-funded |
| X |
|
Group plan* (you buy through work or an association): Exempt self-funded or non-Employee Retirement Income Security Act (ERISA) |
|
| X |
Group plan* (you buy through work or an association): Fully insured | X |
|
|
Other health plans, including government-sponsored: APPLE Health (Medicaid) | X |
|
|
Other health plans, including government-sponsored: Original Medicare (Parts A and B) and Medicare prescription drug coverage (Part D) |
| X |
|
Other health plans, including government-sponsored: Medicare Advantage |
| X |
|
Other health plans, including government-sponsored: Dept. of Social and Health Services Medicaid (Provider One) | X |
|
|
*Double check with your human resource department to clarify which type of policy your plan is.
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 (leg.wa.gov).
- Accident-only coverage
- Coverage provided from an auto or homeowner personal injury claim
- Critical illness coverage (a policy for serious illness, like cancer)
- Dental-only and vision-only coverage
- Disability-income insurance
- Employer-sponsored self-funded health plans
- Fixed-payment indemnity or mini-med insurance
- Limited health care services
- Long-term care insurance
- Medicare supplemental coverage
- Short-term limited purpose insurance (i.e., student coverage)
- Worker's compensation coverage