The Health 

Insurance Marketplace: 

Know Your Rights

You have certain rights when you enroll in a Marketplace health plan. These rights include:

• Getting easy-to-understand information about what your plan covers, what you pay for services

out-of-pocket, what drugs it covers, and what providers are in its network.

• Getting coverage for emergency services.

• Requesting coverage for a prescription drug that’s not normally covered by your plan.

• Appealing a health plan’s decision not to pay a claim.

Depending on where you live, your state may offer other rights and protections. Contact your local 

Department of Insurance for more information.

Getting plan information

You have the right to get an easy-to-understand ”Summary of Benefits and Coverage” (SBC) when 

shopping for or enrolling in coverage. This summary outlines what the plan covers and what those 

services would cost you out-of-pocket. The SBC also includes coverage examples for diabetes care 

and childbirth, so you can see how a particular plan’s cost sharing might work for a medical situation.
In addition to the SBC, insurance companies must also give you a “Uniform Glossary” with certain 

terms used in health coverage and medical care. All plans must use the same standard form for the 

SBC and “Uniform Glossary” to help you compare plans.

How can I get a plan’s SBC and “Uniform Glossary”? 

The SBC is available for every Marketplace plan. You’ll find a link to it on each plan’s page when you 

enroll through HealthCare.gov. You can also ask for a SBC from your insurance company at any 

time. All health plans must provide it to you at important points in the enrollment process, like when 

you apply for or renew your policy. You can also ask for a copy of the “Uniform Glossary” to help you 

understand common words used in health care.

Can I get a SBC and “Uniform Glossary” in another language?

If you don’t speak English, you may be able to get a copy of the SBC in your preferred language. Look 

for a statement on the SBC in your preferred language to see if it’s available. It will include a phone 

number you can call to request the translated version from your insurance company. 

The ”Uniform Glossary” is available in Chinese, Navajo, Spanish, and Tagalog at CMS.gov/cciio/

programs-and-initiatives/consumer-support-and-information/summary-of-benefits-andcoverage-and-uniform-glossary.html.

What’s a provider directory?

A health plan’s provider directory (also called a provider network directory) lists the network of doctors, 

hospitals, and other health care providers that contract with that health plan to give you medical 

care. If you use a doctor or facility that’s not in your plan’s network, you may have to pay more for the 

services you get.

When you’re shopping for a health plan, use the plan’s provider network directory to search for your 

current doctor. You can also use the provider network directory on your health plan’s website to find 

a new doctor.

Every Marketplace plan must have a provider network directory link on its website — and the 

directory should have the most current listing of network providers to help you with your enrollment 

decisions. When you’re ready to enroll or you want to preview plans and prices on HealthCare.gov, 

you’ll see direct links to provider directories for every Marketplace plan.

How can I find out if a plan covers my prescription drugs?

HealthCare.gov provides links to lists of covered drugs for all Marketplace plans. Your SBC will include a 

link on how you can get more information about your prescription drug coverage.

Coverage of emergency services

Every Marketplace plan, except dental plans, must cover hospital emergency services without prior 

authorization, even if the service is provided out-of-network.
What if I get emergency care out-of-network?

Your plan must cover out-of-network emergency care without:

• Limiting coverage in ways that are more restrictive than in-network limits.

• Charging you a copayment or coinsurance that’s more than the cost for in-network care.

You may have to pay other costs, like a deductible, if it applies to your out-of-network benefits.

Can my health plan have conditions of coverage for emergency care?

Generally, your plan must cover emergency services regardless of any other term or condition of 

coverage. If the particular service you get isn’t covered by your plan, you may have to pay the total 

cost of that service if you don’t have other coverage.

Requesting coverage for a prescription drug that’s not covered by your plan

Every Marketplace plan must have a prescription drug exceptions process that allows you to request 

coverage of a prescribed drug not covered by your plan. This process is different than appealing the 

denial of a drug that’s covered. The information below describes the recommended process, but the 

details of your plan’s process may be different. Contact your plan for detailed information about its 

prescription drug exceptions process.

How do I request an exception for a non-covered drug prescribed by my doctor?

To request a drug through the exceptions process, your doctor would generally submit a request 

to your plan (orally or in writing) that the non-covered drug is clinically appropriate for your 

medical condition.

Can I get the non-covered drug during the exceptions process?

While you’re in the exceptions process, your plan may give you access to the requested drug until a 

decision is made, but it isn’t required to.

What happens if I get the exception?

If you get the exception, you can generally get the non-covered drug for a certain period of time. 

Your health plan will generally treat the drug as covered, but your share of the cost (like your 

coinsurance) could apply to the most expensive drug tier on the formulary (or drug list). If your 

plan covers the drug through the exception, your share of the cost will count towards your out-ofpocket maximum.

Getting help with your appeal

Here are some resources to help you with your appeal:

• Contact your state’s Consumer Assistance Program (CAP) or Department of Insurance. 

They may be able to help you, along with other local organizations. Visit LocalHelp.HealthCare.

gov to find help in your area.
• Get help in your preferred language. If you don’t speak English, you can get help and 

information about appeals and other Marketplace issues in your preferred language at no cost. 

To talk to an interpreter, call the Marketplace Call Center at 1-800-318-2596. TTY users can call 

1-855-889-4325.

• Appoint an authorized representative to help you. Your representative can be a family 

member, friend, advocate, attorney, or someone else who will act for you. This can be done 

several ways, depending on the type of appeal you’re filing. Visit HealthCare.gov to get the 

forms you’ll need to appoint a representative. 

• Learn about the steps to file an appeal. Learn about the steps for appealing your insurance 

company’s decision at Marketplace.cms.gov/outreach-and-education/appealing-your-insurersdecision-not-to-pay.pdf.

You have the right to get Marketplace information in an accessible format, like large print, Braille, or audio. You also have 

the right to file a complaint if you feel you’ve been discriminated against. Visit CMS.gov/about-cms/agency-information/

aboutwebsite/cmsnondiscriminationnotice.html, or call the Marketplace Call Center at 1-800-318-2596 for more 

information. TTY users can call 1-855-889-4325.

Paid for by the Department of Health & Human Services.

CMS Product No. 11759

Revised August 2018