What this is
This guide is a starting map. Health insurance in the United States is not one system—it is a patchwork of federal programs, state programs, employer benefits, and private plans. The type of coverage you have changes which laws apply, which agency can help if something goes wrong, and which appeal steps actually work.
If you are new to patient advocacy, plan type is one of the first questions to answer before you file an appeal or call a regulator. The Appeals Roadmap describes what to do after a denial; the guides below explain whose rules you are arguing under.
This is general information to help you orient—not legal advice.
Why plan type matters
Two patients can receive the same denial letter wording—“not medically necessary” or “prior authorization required”—but have very different rights. One may have a state external review with an independent medical reviewer. Another may be limited to federal employer-plan rules. One may appeal to Medicare; another to a state Medicaid fair hearing.
Using the wrong playbook wastes time. Calling a state insurance department about a self-funded ERISA plan may yield limited help. Filing a Medicare appeal form for a Marketplace plan will not work. Matching the patient to the right plan category saves deadlines and points you to the right documents.
Private coverage models (this topic)
These guides live on the Insurance topic because they behave like commercial coverage:
Employer-sponsored plans (job-based)
Coverage through work—often called a group health plan. It may be fully insured (the employer buys a policy from an insurance company) or self-funded (the employer pays claims directly, often under ERISA). See Employer plans and Self-funded ERISA plans.
Marketplace (ACA) plans
Coverage bought through HealthCare.gov or a state-based exchange, with federal benefit standards and state insurance oversight. See Marketplace plans.
Medicare & Medicaid
Federal Medicare and state Medicaid are not private insurance—they have their own enrollment, benefits, regulators, and appeal systems. Depth guides live under Medicare & Medicaid within Insurance, including:
- Medicare basics and Original Medicare
- Medicare Advantage and Medicare Part D
- Medicaid basics, Medicaid managed care, and Medicaid fee-for-service
- Dual-eligible patients
TRICARE, VA, Indian Health Service, and short-term plans are not covered here yet—identify the program from the patient's card and official enrollment materials.
How to tell what you have
Look at the insurance card, the denial letter, and any enrollment materials. Ask:
- Does the card say Medicare or show a Medicare number? If yes, confirm whether it is Medicare Advantage (Part C) or another Medicare product.
- Does paperwork say Medicaid, a state program name, or a managed care plan like Molina, Anthem Medicaid, or UnitedHealthcare Community Plan? That suggests Medicaid managed care in many states.
- Was coverage bought on HealthCare.gov or a state exchange, or does the plan document say Qualified Health Plan (QHP)? That points to Marketplace coverage.
- Is coverage through an employer? Check whether materials say self-funded, self-insured, ERISA, or administered by a TPA. If not, it may still be fully insured through a major insurer name.
When still unsure, call the number on the card and ask: "Is this plan fully insured or self-funded?" "Who is the regulator for appeals?" Request the answer in writing. For state-specific regulator lists, use State insurers & legislation on the Insurance topic page.
Denials and regulators at a glance
Every plan type uses an appeal to challenge a specific denial or coverage decision. A regulator complaint is different—it asks an agency whether the company followed the rules. See Complaints to regulators.
At a high level:
- Fully insured employer and Marketplace plans: state insurance department often plays a large role; external review may be available in many states.
- Self-funded ERISA employer plans: federal ERISA and Department of Labor oversight; state insurance department authority is often limited for the plan itself.
- Medicare (all parts): Medicare appeal levels and CMS—see Medicare appeals & grievances.
- Medicaid: plan grievance/appeal plus state Medicaid agency and fair hearings.
Build your record the same way regardless of plan type—see Building a strong appeal packet.
Where to go next
Open the guide that matches the patient's coverage. For private plans, use the links below and the Appeals Roadmap. For Medicare or Medicaid, open the Medicare & Medicaid hub.
Bottom line
Plan type is not a technical detail—it is the frame for every appeal and complaint. Identify coverage first, use the matching plan-type guide, then follow the Appeals Roadmap with the right regulator and external review options in mind.