Fully Insured and Marketplace Plans: How Appeals Work

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

Many people get health coverage from a policy an insurance company issues. This is called a fully insured plan. It includes individual and family plans, Marketplace plans, and plans an employer buys from an insurer.

These plans follow state insurance law plus federal minimum rules from the Affordable Care Act (ACA). This guide explains how both fit together for people in Kentucky and Indiana. It is part of the Coverage & Appeals Center.

First: is your plan fully insured?

Your plan is likely fully insured if:

• You bought it yourself, on or off the Marketplace.
• Your employer buys a policy from an insurance company.

Your plan is likely not fully insured if your employer pays claims with its own money. That is a self-funded plan, and federal rules apply instead. See self-funded employer plans. Not sure? Ask HR or call the number on your card: “Is my plan fully insured or self-funded?”

Marketplace plans. Kentucky runs its own Marketplace, called kynect. Indiana is not a state-based Marketplace, so Indiana residents use HealthCare.gov (CMS: State-based Exchanges). Either way, appeals of a medical denial go to the insurance company that issued your plan.

The federal minimums

Federal rules set a floor that applies to insurers in both states (45 CFR 147.136(b)):

• Time to appeal: at least 180 days after you get the denial (29 CFR 2560.503-1(h)(3)(i)).
• Decision times: 72 hours for urgent care, 30 days for care you have not received yet, and 60 days for care you already received (29 CFR 2560.503-1(i)(2)). Plans with two appeal levels split the time between them.
• Free records: you can get free copies of the documents, criteria and codes used for your claim (29 CFR 2560.503-1(h)(2)).
• Your evidence counts: the plan must consider everything you send, even if it is new.
• One level for individual plans: plans you buy yourself may have only one level of internal appeal.
• External review: if the plan still says no on a medical question, you can ask an independent reviewer.

Appeals at a glance: Kentucky and Indiana

Your denial letter may list a different deadline. Use the earliest date that applies. The appeal deadline calculator can help.

Kentucky fully insured plans

Internal appeal

Most Kentucky plans must give you at least 180 days to appeal; check your denial letter. The insurer generally decides within 30 days, or within 72 hours if your appeal is expedited (KY DOI UM Review Guide (2026); KRS 304.17A-617).

External review

You can ask for external review through your insurer within 4 months of the final internal denial. The insurer assigns an independent review entity. The reviewer decides within 21 days after it gets your file, and no more than 45 days after your request. Expedited reviews take no more than 72 hours (KRS 304.17A-623; KY DOI UM Review Guide (2026)).

• What qualifies: denials for medical necessity and for care called experimental or investigational (KRS 304.17A-600).
• Plan exclusions: if the plan says a service is excluded, you can ask the Department of Insurance to review it first. If a medical issue needs to be resolved, the insurer must cover the service or offer external review (KRS 304.17A-617).
• Your paperwork: you sign a medical records release. The insurer completes form HIPMC-IRE-6 (806 KAR 17:290).
• Cost: a one-time $25 filing fee, refunded if you win. It can be waived for financial hardship, and there is a $75 yearly cap (KRS 304.17A-623).
• Result: the decision is binding on the insurer (KRS 304.17A-625).

More detail is in the Kentucky guide.

Indiana fully insured plans

Internal grievance and appeal

Indiana uses two internal steps. First you file a grievance. If the insurer still says no, you can appeal the grievance decision.

• Filing: you can file a grievance by phone or in writing (IC 27-8-28-14). Indiana law sets no filing deadline. Follow the deadline in your denial letter or policy (IDOI: Grievance Procedures).
• Grievance decision: within 20 business days after the insurer has the information it needs. It can take 10 more business days if the insurer tells you in writing (IC 27-8-28-16).
• Appeal decision: within 45 days after you file the appeal. For medical necessity denials, a panel that includes a reviewer in a similar specialty decides. You may appear in person (IC 27-8-28-17).
• Urgent cases: Indiana law requires timelines that fit the clinical urgency. Federal rules require a decision within 72 hours for urgent care.

External grievance (external review)

• Deadline: within 120 days after the plan’s decision on your appeal, filed with your insurer (IC 27-8-29-13).
• Form: Indiana has no standard state form. Ask your insurer for its external review request form.
• What qualifies: denials for medical necessity, appropriateness, care called experimental or investigational, and a decision to cancel (rescind) your policy (IC 27-8-29-12).
• Decision: within 15 business days, or within 72 hours if expedited (IC 27-8-29-15).
• Cost: the insurer pays the reviewer’s costs.
• New information: you can send more information throughout the review (IC 27-8-29-14).
• Result: the decision is binding on the insurer (IC 27-8-29-16).

HMOs. HMOs follow their own chapters with similar steps: 20 business days for a grievance, 45 days for an appeal, and 120 days to ask for external review (IC 27-13-10-7; IC 27-13-10.1-2).

More detail is in the Indiana guide.

Prior authorization rules for Marketplace plans

The 2026 federal prior authorization rule (CMS-0057-F) sets 72-hour and 7-day decision deadlines. Those deadlines apply to Medicare Advantage and Medicaid, not to Marketplace or employer plans. Marketplace plans on the federal platform, such as Indiana’s HealthCare.gov plans, must still give a specific reason when they deny prior authorization (CMS-0057-F). Plans on a state-run Marketplace like kynect are not listed in that rule.

How to appeal a fully insured plan’s denial

1. Read the denial letter. Copy the exact reason and the deadline. Use the denial decoder if the codes are unclear.
2. Ask for your claim file. Request the criteria and documents the plan used. They are free.
3. Get your clinician’s letter. Ask for a letter that answers the denial reason point by point.
4. Send your internal appeal. In Indiana, this first step is called a grievance. Keep proof you sent it.
5. Ask for an expedited review if it’s urgent. Say that waiting could seriously harm your health.
6. Request external review if the plan still says no. In Kentucky, within 4 months. In Indiana, within 120 days. Send it to your insurer.

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Insurer name] — Appeals or Grievances
[Address or fax from your denial letter]

RE: Appeal of denial
Member name: [Name] · Member ID: [Number]
Claim or reference number: [Number]
Service denied: [Service]
Date of denial letter: [Date]

To whom it may concern:

I am appealing your decision to deny [service]. Your letter says: "[exact reason]."

I believe this care meets your policy, [policy name or number]. My clinician explains why in the enclosed letter.

Enclosed are:
- Letter of medical necessity from [clinician]
- Medical records from [dates]
- Your policy with the criteria I meet marked
- Your denial letter

Please send me a free copy of my claim file and the criteria you used.

[If urgent:] My clinician believes waiting could seriously harm my health. I request an expedited review.

If you uphold the denial, please tell me in writing how to request an external review.

Sincerely,
[Signature]
[Printed name]

The appeal letter builder can fill this in for you.

Common mistakes

• Sending the external review request to the state. In both Kentucky and Indiana, you send it to your insurer.
• Skipping Indiana’s second internal step. Appeal the grievance decision before asking for external review.
• Assuming the 72-hour prior authorization rule applies. It covers Medicare Advantage and Medicaid, not Marketplace plans.
• Using the state process for a self-funded plan. Those plans use the federal process.

Where to get help

Both departments take complaints in writing. Not sure which route fits? Try the appeal route wizard.