Most health plan problems fall into five groups: denied claims, billing errors, network changes, drug list changes and ID card or payment issues. Each one has a clear fix. You can appeal a denial within 180 days, dispute a wrong bill, and ask for up to 90 days of continued care when a doctor leaves. Here's how to handle each one.
- HealthCare.gov insurers denied 19% of in-network claims in 2024, yet people appealed fewer than 1% of those denials.
- You have 180 days after a denial notice to file an internal appeal with your plan.
- If your doctor leaves the network during certain treatment, you may get up to 90 days of continued care.
- Your coverage can be active before your ID card arrives, so call your insurer to confirm.
- With a tax credit, you usually get a 3-month grace period for a missed premium.
The most common health plan problems and who to call
When something goes wrong, the hardest part is knowing where to start. So we sorted the issues we hear most often on the phones. Use this table to find your first call.
| Problem | First call | Usual fix |
|---|---|---|
| Denied claim | Doctor's billing office | Corrected claim or an appeal |
| Wrong or surprise bill | Your insurer, then the provider | Match the bill to your EOB |
| Doctor left the network | Your insurer | Continuity of care or a new doctor |
| Drug moved tiers | Your prescriber | Formulary exception request |
| No ID card yet | Your insurer | Confirm payment and start date |
Most coverage problems are fixable, but deadlines apply. Your next step: find your row, then jump to that section below.
Denied claim? Fix it in four steps
A denial isn't always the final word. In fact, KFF found that a quarter of in-network denials on HealthCare.gov plans in 2024 were for administrative reasons, like missing information. So start with the simple fixes first.
- Read the denial reason
Check your Explanation of Benefits, or EOB, for the reason code. It tells you what went wrong.
- Call the billing office
Ask whether they used the right code. Often they can send a corrected claim, and no appeal is needed.
- File an internal appeal
Submit it within 180 days of the denial notice. Include your doctor's letter and records.
- Ask for an external review
If the plan still says no, request an independent review within 4 months of the final denial.
An external reviewer's decision binds the insurer. Also, urgent cases can use a faster, expedited review. Our guide to the full path a medical claim takes explains each stage. When you're ready to appeal, follow our steps to write a strong appeal letter.
Billing errors and surprise bills
Billing mistakes are among the most common health plan problems. For example, a provider may bill you before your insurer pays. Or a bill may show the wrong date, the wrong code or a service you never got.
First, remember that an EOB is not a bill. It shows what the plan paid and what you may owe. So compare every bill to its EOB before you pay. If the bill asks for more than your EOB shows, call the provider and ask why.
Know your surprise billing rights
The No Surprises Act protects you from many surprise bills. For instance, it covers most emergency care, certain care at in-network hospitals and air ambulance trips. In those cases, you generally pay only your in-network share. If you think a bill breaks these rules, call the No Surprises Help Desk at 1-800-985-3059.
Our guide to how medical bills and EOBs fit together covers the details. Your next step: hold any bill that doesn't match its EOB until you get an answer.
If we're your agent, a licensed Vivna agent can help you sort out what went wrong and who to call, at no cost.
Doctor and drug changes: common coverage problems
Networks and drug lists change, sometimes in the middle of treatment. These health plan problems feel scary, especially during care. Still, you have more rights than most people think.
Your doctor left the network
Under federal law, you may keep seeing that doctor at in-network rates for up to 90 days. This continuity of care applies if you're in treatment for a serious condition, pregnant, scheduled for non-elective surgery or receiving inpatient or terminal care. So call your insurer and ask for it by name.
Also, if the plan's directory listed a doctor as in-network by mistake, your cost is limited to the in-network amount. Read what to do when your doctor leaves for the full checklist.
Your drug moved tiers or left the list
ACA plans must offer a formulary exception process. Your prescriber asks the plan to cover a drug that isn't on its list. The plan must decide within 72 hours, or within 24 hours in urgent cases. Meanwhile, ask your doctor whether a covered drug would work just as well.
- Ask for continuity of care if you're mid-treatment
- Request a formulary exception through your prescriber
- Save screenshots of the directory listing you relied on
ID cards, payments and other coverage problems
New members often call because their card hasn't arrived. However, your coverage may already be active without it. So call your insurer, confirm your start date, and ask for your member ID number. Many insurers also show a digital card in their app.
Next, check your payment, because unpaid premiums cause many health plan problems for new members. On a new Marketplace plan, coverage generally won't start until you pay your first premium. You pay the insurer directly, not the Marketplace. Our guide on what each part of your card means helps once it arrives.
If you use a tax credit and miss a premium, you usually get a 3-month grace period. But if you don't catch up by the end of it, coverage can end back to the first unpaid month. Without a credit, your state's grace period may be different.
Health plan problems at renewal time
Open Enrollment brings its own set of issues. For example, you might get auto-renewed into a plan you never picked. Or your tax credit may rest on last year's income. Our guide on what happens when your plan renews walks through each one.
Carrier exits are the biggest renewal problem this year. For 2027, Cigna is leaving the individual market in all 11 states where it sold plans. Molina is also leaving Florida's individual Marketplace. So members of either plan should pick a new one by December 15 to keep a January 1 start. Floridians can compare options on our Florida coverage and carriers page.
When health plan problems mean it's time to switch
One bad claim doesn't mean you need a new plan. However, a pattern of problems often does. Use these cards to decide.
Fix it with the provider and your insurer, then keep the plan.
Compare plans with a broader network at Open Enrollment.
Look for a plan where your drugs sit on a lower tier.
Switch now so you don't land in a plan you didn't choose.
Run our yearly coverage checkup checklist before you decide. Also skim the buying errors that cost people most, so a new plan doesn't bring new trouble.
Keep a simple log for every problem call. Write down the date, the person's name and a reference number. On the phones, that log is often what gets a claim reprocessed. Also, keep every EOB until the plan year ends and every bill is settled.
Call billing before you file an appeal.The first fix our licensed agents suggest for a denied claim
Want to compare plans that fit better? See ACA and private plans in your area, or call 888-730-6031.
Health insurance problems: FAQs
What should I do first if my claim is denied?
Read the reason on your Explanation of Benefits, then call your doctor's billing office. Many denials come from coding errors or missing information, and the office can send a corrected claim. If that doesn't work, file an internal appeal within 180 days. If the plan still denies it, you can ask for an independent external review.
How do I fix a wrong medical bill?
Compare the bill to the EOB for that visit. If they don't match, call the provider's billing office and ask for an itemized bill. Then call your insurer if the claim looks wrong. For surprise bills from emergency care or out-of-network doctors at in-network hospitals, call the No Surprises Help Desk at 1-800-985-3059.
Can I use my insurance before my card arrives?
Often, yes. Your coverage may already be active, even without the card. Call your insurer to confirm your start date and member ID, and ask whether your doctor or pharmacy is enrolled. Many insurers also offer a digital card in their app. Just make sure you paid your first premium.
What if my doctor leaves my plan mid-year?
If you're in active treatment for a serious condition, pregnant or scheduled for surgery, you may get up to 90 days of continued care at in-network rates. Ask your insurer for continuity of care. Otherwise, pick a new in-network doctor, and look for a plan that includes your doctor at the next Open Enrollment.
Should I switch plans because of coverage problems?
Not after a single issue. Instead, fix the problem first, then look for a pattern. If doctors keep leaving, drug costs keep climbing, or your carrier is exiting, comparing plans at Open Enrollment makes sense. A licensed agent can check whether a new plan actually solves the problem.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- HealthCare.gov: Internal appeals
- HealthCare.gov: External review
- KFF: Claims denials and appeals in ACA Marketplace plans in 2024
- CMS: No Surprises Act key protections
- 45 CFR 156.122: Prescription drug benefits and exceptions
- HealthCare.gov: Health insurance grace period
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time.
Related guides
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More local help: the North Carolina health insurance guide, plus guides for Florida, Texas, Georgia and every state we serve.
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