What Can You Appeal?

If you disagree with a decision made by the Marketplace, you typically have 90 days from the date on your Eligibility Notice to request an appeal.

Important: If the Marketplace asked you to submit documents to verify your application information, do that first. You may receive an updated eligibility decision, which could eliminate the need for an appeal. Learn more about submitting documents.

You can appeal if the Marketplace determined that you are ineligible to:

• Purchase a Marketplace plan or Catastrophic coverage.
• Receive financial assistance with Marketplace costs (including disagreements about the amount you qualify for).
• Enroll in or change your Marketplace plan during a Special Enrollment Period.
• Obtain an exemption.

You can also appeal:

• If the Marketplace delayed informing you of your eligibility results.
• The start date of your Marketplace coverage.
• Other specific decisions, depending on your state.

If you live in Alabama, Alaska, Louisiana, Montana, Virginia, West Virginia, or Wyoming, you may also appeal if you're deemed ineligible for Medicaid or the Children's Health Insurance Program (CHIP).

If your state has its own Marketplace website, you should appeal directly through their system. Check your state's specific procedures.

How to File an Appeal

The process for filing an appeal, including the form you’ll need, varies based on your location and whether you have a Marketplace account.

What Happens After You File an Appeal?

Acknowledgment: Once we receive your appeal request, we'll send you a letter confirming receipt.

1. Appeal Review:

1. • Accepted Appeals: We will review your appeal and any documents you submitted.
   • Invalid Appeals: If your appeal is deemed invalid, you may need to provide additional information or seek alternative assistance. Learn more about what to do if your appeal is invalid [here](PDF, 171 KB).

2.Check Appeal Status (if you have a Marketplace account):

1. • • Log in to your Marketplace account.
     • Select your current application.
     • Go to "Eligibility & appeals" and click on "File new appeal or check your appeal's status."

3.Processing Timeline: Appeals are processed in the order they are received. The time it takes to reach a decision depends on the complexity of the issue, whether the appeal is expedited, and if additional documents are needed.

1.Steps to Resolve Your Appeal:

• • Appeal Submitted: Your appeal has been received.
  • In Review: We are reviewing your appeal form and any documents submitted.
  • Informal Resolution: We will follow up with you if we need more information. You will receive a letter with the results of the informal resolution.
  • Hearing: If you disagree with the informal resolution, you can request a formal hearing.
  • Decision: Once a final decision is made, you will receive a letter outlining the next steps.

Requesting a Faster Appeal

If waiting for a standard appeal decision could seriously impact your health, such as being in the hospital or needing urgent medication, you can request an expedited appeal. Be sure to mention your health concerns when you file your appeal.

How to Request an Expedited Appeal:

• Online: When filing your appeal online, select "Yes" when prompted to request a faster appeal.
• On the Appeal Request Form: Indicate that you need an expedited appeal and provide details about your health situation.
• In a Written Request: If you're submitting your appeal by letter, clearly state your need for an expedited review and explain your health reasons.

Timeline for Expedited Appeals:

The time it takes to receive a decision depends on the nature of the appeal and whether additional documents are required. Expedited appeals are prioritized and generally resolved more quickly.

We will send you a confirmation letter acknowledging receipt of your appeal request and providing details about the expedited process.

To ensure a swift resolution, respond promptly to any requests for additional information.

Getting Help with Your Appeal

Find Local Assistance

You can seek help from local resources who can guide you through the appeal process, answer your questions, and offer unbiased support.

Appointing an Authorized Representative

You have the option to appoint someone you trust, such as a family member, friend, advocate, or attorney, to act on your behalf during your appeal. This person will be your primary contact for all communications regarding your appeal, including updates via text or email.

Role of an Authorized Representative:

• Communications: They will handle all communications related to your appeal.
• Support: They will provide information and documents needed to support your appeal.
• Actions: They will manage phone calls, attend conferences or hearings, and perform any necessary actions for your appeal.
• Decisions: They will inform us of your decisions regarding your appeal outcome, such as which plan you wish to enroll in.

If you have already appointed a representative for your Marketplace application, you will need to appoint them again specifically for your appeal.

How to Appoint a Representative:

• Online or Paper Form: When you file your appeal request, indicate your representative in the appropriate section of the online or paper form.
• Post-Appeal Appointment: If you have already submitted your appeal or are submitting a letter, send a completed form or letter to the Marketplace Appeals Center.

To Appoint a Representative by Letter:

Include the following details in your letter:

• Your name, address, and phone number
• Your appeal number (if applicable)
• A statement appointing the individual as your representative
• The representative’s name, address, and phone number
• A statement authorizing the Marketplace Appeals Center to discuss your appeal with your representative
• Your signature and the date

Decisions Employers Can Appeal

As an employer, you can appeal a Marketplace decision if it indicates that the health coverage you offer does not meet the minimum legal standards.

When to Appeal:

• Minimum Standards: If you are required to provide coverage to full-time employees (and their dependents) that meets specific minimum standards, and the Marketplace has determined that you did not meet these standards, you may face an Employer Shared Responsibility Payment (ESRP). The IRS decides whether you owe this fee.

• Small Business Health Options Program (SHOP): If your business applied for SHOP and received a decision you wish to contest, you can appeal that decision.

Employer Appeals in the Marketplace:

To appeal, you must show that your employee(s) were enrolled in or offered health coverage that:

• Is Affordable: Meets the affordability criteria.
• Provides Minimum Value: Meets the minimum value requirements.

Filing an appeal with the Marketplace does not affect your responsibility for any potential IRS fee, which requires a separate appeal with the IRS.

Impact on Employees:

The outcome of your appeal may affect whether your employees and their household members qualify for cost savings and premium tax credits through the Marketplace. If the coverage offered was affordable and met minimum value requirements, employees might have to repay any savings received when filing their taxes.

When you file an appeal, your employees will receive a letter outlining the appeals process, its potential impact on their eligibility for savings, their rights, and instructions for submitting relevant documents.

How to File an Employer Appeal:

You have 90 days from the date of the Marketplace notice to file your appeal. You can choose one of the following methods:

1.Complete the Appeal Form:

1. • Include copies of documents verifying:
     • Coverage was offered to the employee listed.
     • The coverage was affordable.
     • The coverage provides minimum value.

2. Submit a Letter:

• • Include the following details:
    • Business name
    • Employer Identification Number (EIN)
    • Primary contact information (name, phone number, and address)
    • Reason for the appeal
    • Information from the Marketplace notice (date and employee details)
    • Copies of documents verifying the offer, affordability, and minimum value of the coverage.