Marketplace appeals for NC navigators Presented by: Madison hardee, January 2015

WHAT can be appealed? Eligibility to buy a Marketplace plan The amount of APTC The level of CSR Eligibility for a Special Enrollment Period Eligibility for an exemption from the individual responsibility requirement

How to appeal? Form must be mailed. It cannot be submitted online this year. Appeal request form English: https://www.healthcare.gov/downloads/marketplace-appeal-request-form-a.pdf Spanish: https://www.cuidadodesalud.gov/downloads/es/marketplace-appeal-request-form-a.pdf

Appeal FORM NC uses a different form than some other states

Appeal FORM Appellant is the person requesting the appeal. If there are multiple people in the HH and they have each have an issue, include their names as appellant 1, 2, 3, 4, etc..

Appeal FORM Help consumer explain exactly why they are appealing – may be easier to type this up and attach. If you do this, write "See Attached" in the form.

Appeal FORM As a navigator, you will fill out bottom portion with your #. This just indicates that you helped the consumer with completion of the form. It does not authorize you as their representative. If wish you wish to be authorized rep, fil out top. If not, someone from legal aid can do this later.

When should a consumer appeal? Help consumer appeal as soon as possible Assist with completion of appeal form Deadline to appeal: 90 days from the date of the eligibility determination

Appeal submitted – now what? Usually takes 1-2 weeks to receive a letter acknowledging that the appeal was received After 30 days, should receive a call from the appeal center. If appellant has not heard anything, they should contact the eligibility appeals center directly at 1-855-231-1751 to check on the status of their eligibility appeal. 

Submitting additional documentation The appeal center may request supporting documentation. Or, the consumer may wish to send supporting documentation prior to a hearing. Proof of income Proof of eligible immigration status Copy of the eligibility notice Send to: Marketplace Eligibility Appeals Center P.O. Box 311 Pittston, PA 18640

Formal resolution/ hearing Appeal initiation Informal resolution Formal resolution/ hearing Appeal process Request processed and acknowledged Receive eligibility determination Conduct hearing by phone Complete and submit appeal request Informal resolution attempted Receive Appeal decision Submit supporting documentation

Referrals for legal assistance Pisgah Legal Services: 828-253-0406 Buncombe, Henderson, Madison, Polk, Rutherford, and Transylvania Counties Legal Services of Southern Piedmont: 704-376-1600 Mecklenburg County Legal Aid of NC: 866-219-5262 All 100 Counties Legal assistance is available! You can refer them at any stage in the appeals process, but especially should refer for a hearing. To be eligible for Legal Services or Legal Aid, clients generally must be under 200 percent of the Federal Poverty Line. Pisgah Legal Services, provides free civil legal aid primarily in Buncombe, Henderson, Madison, Polk, Rutherford and Transylvania Counties, with offices located in Asheville, Hendersonville and Spindale. Legal Services of Southern Piedmont, located in Charlotte, NC, provides legal assistance in civil matters to low-income persons in the Charlotte area. Legal Aid of North Carolina, Inc. is a statewide legal services organization in North Carolina. LANC represents low-income persons in a variety of legal matters in 20 locations across the state and using a statewide hotline.

Implementation of appeal decisions Prospective Marketplace must implement the appeal decision effective: First day of month following notice of appeal decision If after the 15th, may be one month later Effective date may be changed, based on circumstances Retroactive Available at the option of the individual Effective date based on initial date of application APTCs and CSRs also applied retroactively Consumer responsible for paying past premiums Feb 27 CMS retro coverage memo – Marketplace may establish an effective enrollment date based on the date that the individual originally submitted an application for coverage to the Marketplace. The individual will be treated for all purposes as having been enrolled in the QHP since the effective enrollment date. The individual will be responsible for their portion of the premium for the retroactive coverage period. If the Marketplace determines the individual eligible for APTCs and CSRs, and assigns the individual to a cost-sharing reduction plan variation, CMS will pay advance payments of the PTC and CSRs to the Marketplace QHP issuer on a retroactive basis, based on the effective enrollment date established by the Marketplace. The regulation on retroactive coverage post-appeal is at 45 CFR 155.545(c):   (c) Implementation of appeal decisions. The Exchange, upon receiving the notice described in paragraph (b), must promptly— (1) Implement the appeal decision effective— (i) Prospectively, on the first day of the month following the date of the notice of appeal decision, or consistent with §155.330(f)(2) or (3), if applicable; or (ii) Retroactively, to the date the incorrect eligibility determination was made, at the option of the appellant. (2) Redetermine the eligibility of household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in §155.305.

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