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How can I appeal a decision in the health insurance Marketplace?



Are you unhappy with a health insurance decision that has been made for you in the Marketplace? If so, you may appeal the unfavorable decision. You must file the appeal within 90 days after receiving the notice from the Marketplace. Appeals can concern decisions related to:

• Eligibility to buy a Marketplace plan
• Enrolling in a Marketplace plan outside of open enrollment
• Eligibility for an advanced premium tax credit
• Eligibility for cost-sharing reductions
• Eligibility for Medicaid or the Children’s Health Insurance Program (CHIP)
• Eligibility for exemption from the requirement to have health insurance

An appeal can be filed by visiting this site.  Download and complete an appeal request form. Mail the completed form, with supporting documentation, to the address listed on the form.

You can also write a letter explaining why you think the Marketplace decision was wrong. Always include supporting documentation. Mail the letter to the Health Insurance Marketplace, Attention Appeals, 465 Industrial Blvd., London KY 40750-0061. An appeal can also be faxed to 1-877-369-0129. Once your appeal is filed, the Marketplace Appeals Center may request more information or documentation from you.

It is important to keep proof of when your appeal was mailed and delivered. If using the U.S. postal service, send your appeal via certified or registered mail with delivery confirmation. If faxing your appeal, remember to keep the fax confirmation. This proof will support the timeliness of your appeal.

If your health situation is urgent, you may request an expedited appeal on the appeal form. Explain why the time for a standard appeal would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function.

You may obtain help to complete the forms. A trusted friend, family member or other person can act as your authorized representative to assist with the appeal. Complete and mail the form “Appoint an authorized representative for my appeal,” available here. The form can also be requested by calling the Marketplace Appeals Center at 1-855-231-1751. Interpreter services also are available at no cost to persons with limited English proficiency by calling the Marketplace Call Center at 1-800-318-2596.

You will receive notice of the informal resolution through the mail. If you agree, the matter shall be considered resolved. If you disagree or are not satisfied with the informal resolution, you may request a formal telephone hearing. A final decision will be sent to you within 90 days from when the appeal was received by the Marketplace Appeals Center.

To find help navigating the Marketplace, go to healthcare.gov and click on “Find local help.”

This article was written by Dennis Dobos and appeared in The Alert: Volume 32, Issue 1. Click here to read a full PDF of this issue!