QUESTION

How do I appeal a marketplace decision?

Individuals with no coverage | Navigating Health Insurance Marketplace Options
ANSWER

You can request an appeal of any marketplace decision, including decisions about:

  • Your eligibility to buy marketplace coverage
  • Your eligibility to buy marketplace coverage outside the open enrollment period through a special enrollment period
  • Your eligibility for Medicaid or CHIP
  • Your eligibility for, or the amount of, premium tax credits or cost-sharing reductions, including the length of time the marketplace takes to make a determination
  • Your eligibility for an exemption from the penalty for not having health insurance in 2018 (45 C.F.R. § 155.505).

After you have applied for coverage in the marketplace, you will get an eligibility notice that explains what you qualify for. If you don’t agree with that notice, you can file an appeal. The notice will explain the process you should follow if you want to appeal. For example, depending on your state and eligibility determination, you may need to file with your state Medicaid or CHIP agency rather than the marketplace. Your letter will explain which process is the one for you to use.

There are two ways to file a marketplace appeal:

  1. Mail or fax in an appeal request form available here. The marketplace secure fax line is 1-877-369-0130.
  2. Mail the appeal request form or write a letter to:
    Health Insurance Marketplace Attn: Appeals 465 Industrial Blvd.
    London, KY 40750-0061

To request an appeal, you’ll have to provide your name and contact information and an explanation of what you are appealing and why. You can submit documents to the marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing. You can also request an expedited appeal on the appeals form or in writing if there is an immediate need for health care services and a standard appeal could jeopardize your life, health or ability to function. (45 C.F.R. § 155.540).

The marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back any subsidies you were ultimately determined to be ineligible for. (45 C.F.R. § 155.525).

After you file an appeal, you will get the following from the marketplace:

  • A letter that states that your appeal was received
  • A letter asking for more information or documentation if needed
  • A Decision, which the marketplace must mail to you within 90 days of receiving your appeal request.

The marketplace will review your completed appeal once it is submitted. Then the marketplace will let you know its decision. If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the marketplace may contact you to try to resolve the dispute informally. (45 C.F.R. § 155.535).

If you need help with your appeal:

Individuals with no coverage
Individuals with coverage
Coverage for small employers
Post enrollment issues