APPEALING ELIGIBILITY DECISIONS IN THE HEALTH INSURANCE MARKETPLACE
Note: This fact sheet is about appealing eligibility decisions in the Health Insurance Marketplace. If you live in a state that has its own Marketplace, in most cases you must first appeal eligibility decisions through your state.
Keep copies of all information related to your appeal. This includes paperwork, notes from phone calls, and any other documentation that’s sent to you, or that you sent to the Marketplace or the insurance company.
You can appeal these kinds of Marketplace eligibility determinations:
- Whether you’re eligible to buy a Marketplace plan.
- Whether you can enroll in a Marketplace plan outside of Open Enrollment.
- Whether you’re eligible for an advanced premium tax credit to lower your monthly Marketplace plan premium.
- The amount of savings you’re eligible for (sometimes called cost-sharing reductions) when you get services through your Marketplace plan.
- Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP) (only if your state allows the Marketplace to determine Medicaid eligibility and if your state allows the Marketplace to consider these appeals).
- Whether you’re exempt from having to pay a fee because you don’t have health coverage.
Important: You must request an exemption from the requirement to have health coverage by filing an exemption request with the Marketplace or the IRS (depending on the type of exemption). If the Marketplace denies your request, you can appeal the denial by using the process described on page 2 under the heading “How do I file a Marketplace eligibility appeal?” If the IRS denies your request, you must appeal through them.
Visit IRS.gov for more information about what to do if you disagree with an IRS exemption denial or want to file an appeal with the IRS. For more information about exemptions, click here. Visit HealthCare.gov to learn more about Marketplace eligibility decisions.
How do I file a Marketplace eligibility appeal?
You can file a Marketplace eligibility appeal by:
- Clicking here and downloading an appeal request form. Complete the form, then mail to the address on the form.
- Writing a letter to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
- Faxing your appeal request to our secure fax line: 1-877-369-0129.
What happens after I ask for a Marketplace eligibility appeal?
After you file an appeal, you’ll get a letter that states that the Marketplace got your appeal. If we accept your appeal, you’ll get an acknowledgement letter that describes the next steps in the appeals process and includes instructions for submitting additional material for consideration, if necessary.
While we process your appeal, we may call you, or you may get a letter from us asking for more information or documentation (like a copy of your passport). If you send this information to us, we may be able to informally resolve your case fairly quickly. We’ll call you to explain your informal resolution and will then send you a notice in the mail explaining it.
In general, we must tell you our decision and mail our response to you within 90 days of when we received your appeal request.
Note: If your appeal isn’t accepted because it wasn’t filed in a timely manner, you’ll get a notice that your appeal was dismissed. If your appeal isn’t accepted for any other reason, you’ll get a letter that explains why your appeal wasn’t accepted and what you need to do to fix the appeal.
What if my health situation is urgent?
You can ask for an expedited (faster) appeal if the time needed for the standard appeal process would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function.
Indicate on the appeal request form that you need an expedited appeal and explain why. Your request to expedite your appeal should explain how a standard appeal would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function. Your request to expedite your appeal will be processed and a decision made as quickly as possible.