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

2. 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
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Marketplace Eligibility Appeals

3. 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
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Marketplace Eligibility Appeals

4. 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
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Marketplace Eligibility Appeals

5. 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
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Marketplace Eligibility Appeals

6. Requesting a Marketplace Eligibility Appeal
Two ways to request a Marketplace eligibility appeal
1. Complete an appeal request form
Available at
2. Write a letter explaining the reason for the appeal
Either way, mail the request to
Health Insurance Marketplace
465 Industrial Blvd.
London, KY
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Marketplace Eligibility Appeals

7. 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
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Marketplace Eligibility Appeals

8. 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
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Marketplace Eligibility Appeals

9. 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 (a)
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Marketplace Eligibility Appeals

10. 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
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Marketplace Eligibility Appeals

11. 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
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Marketplace Eligibility Appeals

12. 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
(TTY: )
The Marketplace Appeals Center can answer appellants’ questions about their appeal
Call (TTY: )
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Marketplace Eligibility Appeals

13. 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 (TTY: )
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Marketplace Eligibility Appeals

14. 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
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Marketplace Eligibility Appeals

15. CMS National Training Program
This training is provided by the CMS National Training Program (NTP). To view all available NTP training materials, or to subscribe to our list, visit
CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html
For questions about training products
This training is provided by the CMS National Training Program (NTP).
To view all available CMS NTP materials, including additional training modules, job aids, educational activities, and webinar and workshop schedules, or to subscribe to our list, visit CMS.gov/outreach-and-education/training/cmsnationaltrainingprogram. For questions about these training products,