Marketplace Eligibility Appeals Eligibility Appeals Process Overview for the Federally- Facilitated Marketplace April 2015

Marketplace Eligibility Appeal Rights If consumers disagree with certain determinations made by the Marketplace, they have a right to ask for an appeal This presentation is about appealing a Marketplace eligibility determination 01/28/2015 Marketplace Eligibility Appeals

Marketplace Eligibility Appeals Appealing a Federally-Facilitated Marketplace Eligibility Determination Consumers who disagree with a Federally- Facilitated Marketplace eligibility determination, or believe a mistake was made may appeal the following Eligibility to enroll in a Qualified Health Plan Eligibility for insurance affordability programs Advanced Payment of the Premium Tax Credit Cost-Sharing Reductions 01/28/2015 Marketplace Eligibility Appeals

Marketplace Eligibility Appeals Appealing a Federally-Facilitated Marketplace Eligibility Determination (Continued) Eligibility for MAGI Medicaid and CHIP for states that have delegated these eligibility determinations and eligibility appeals to the Marketplace Eligibility for a Special Enrollment Period to enroll in a Qualified Health Plan outside the annual Open Enrollment Period Eligibility for an exemption from the individual shared responsibility payment 01/28/2015 Marketplace Eligibility Appeals

Marketplace Eligibility Appeals Appealing a Federally-Facilitated Marketplace Eligibility Determination (Page 3) Failure of the Marketplace to provide a timely eligibility determination notice Eligibility for a Catastrophic plan Consumers in State-Based Marketplace states may appeal to the Federal Appeals Entity from The decision of the State-based Marketplace eligibility appeals entity, or The denial by the State-based Marketplace appeals entity of a request to vacate their appeal dismissal 01/28/2015 Marketplace Eligibility Appeals

Requesting a Marketplace Eligibility Appeal Two ways to request a Marketplace eligibility appeal 1. Complete an appeal request form Available at https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/ 2. Write a letter explaining the reason for the appeal Either way, mail the request to Health Insurance Marketplace 465 Industrial Blvd. London, KY 40750-0061 01/28/2015 Marketplace Eligibility Appeals

When a Marketplace Eligibility Appeal is Received The Federal Appeals Entity (FAE)receives and determines validity of appeals requests Received within 90 days of the contested Federally Facilitated Marketplace eligibility determination or 30 days of a State Based Marketplace appeals decision or notice declining to vacate the dismissal of an appeal FAE has jurisdiction (described on slides 2 and 3) Appeal was requested by consumer or by designated authorized representative If valid, appeal acknowledged and process begins 01/28/2015 Marketplace Eligibility Appeals

Informal Resolution of Eligibility Appeals The Federal Appeals Entity works with appellants to resolve eligibility appeals informally Reviews facts and evidence Phone conversation with appellants Informal Resolution Notice Describes proposed resolution and decision If the appellant is satisfied, appeals decision follows Unless appellant voluntarily withdraws the appeal The appellant may request a hearing if unsatisfied 01/28/2015 Marketplace Eligibility Appeals

Marketplace Eligibility Appeal Hearing Hearings are more formal 15 day written notice Conducted by telephone Federal Hearing Officer presides Appellants and any witnesses under oath Faster process when standard timeframe “could jeopardize the appellant’s life, health or ability to attain, maintain or regain maximum functioning.” 45 CFR Section 155.540(a) 01/28/2015 Marketplace Eligibility Appeals

Eligibility Appeals Decisions After the hearing concludes the Hearing Officer carefully considers all evidence and testimony of the appellant and any witnesses The Hearing Officer promulgates the eligibility appeal decision Mailed to appellant within 90 days from the receipt date of the appeal request or as administratively feasible The decision is final and binding 01/28/2015 Marketplace Eligibility Appeals

Eligibility Appeals Decisions, Continued The decision is then implemented If the decision finds the contested eligibility determination was incorrect Appellant may decide to have it implemented retroactive back as far as the date of contested eligibility determination 01/28/2015 Marketplace Eligibility Appeals

Getting Help With Appeals Consumers can get help with Marketplace eligibility appeals Health Insurance Marketplace Call Center – will help by explaining how to request an appeal 1-800-318-2596 (TTY: 1-855-889-4325) The Marketplace Appeals Center can answer appellants’ questions about their appeal Call 1-855-231-1751 (TTY: 1-855-739-2231) 01/28/2015 Marketplace Eligibility Appeals

Getting Help With Appeals, Continued Navigator program – Navigators can help consumers ask for a Marketplace eligibility appeal Appointed representative - can request a Marketplace eligibility appeal and speak for the consumer Call the Marketplace Appeals Center for more info 1-855-231-1751 (TTY: 1-855-739-2231) 01/28/2015 Marketplace Eligibility Appeals

Marketplace Eligibility Appeals Key Points to Remember To file an eligibility appeal with the Marketplace, consumers can write a letter or complete an appeal request form and either way, mail it The Marketplace Appeals Center will try to resolve eligibility appeals informally Appellants have a right to a hearing Decisions are in writing and mailed within 90 days of the appeals request or as administratively feasible 01/28/2015 Marketplace Eligibility Appeals

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