Appealing Decisions within State Health Insurance Exchanges

Appealing a Marketplace Decision

The new Affordable Care Act health plans are now open for enrollment. These plans offer four tiers of healthcare coverage. The four tiers of plans (bronze, silver, gold, and platinum) are also called the “metal” plans and indicate the percentage of covered medical expenses paid for by the health plan.

For consumers whose income is at or below 400% of the Federal Poverty Level, a state health insurance exchange can determine their eligibility for premium tax credits, which are subsidies extended to individuals and families that meet a certain income threshold. These tax credits are used to lower the cost of monthly premiums and will be paid directly to the insurance company after purchasing a health plan. The exchange tools can also determine a consumer’s eligibility for Medicaid or the Children’s Health Insurance Program (CHIP).

The ACA gives consumers the right to appeal a decision made by an exchange. Consumers are guaranteed the right to appeal the following:

  • Eligibility to purchase an exchange plan
  • Eligibility to purchase a plan outside of the regular open enrollment period
  • Premium subsidies
  • Medicaid or CHIP eligibility
  • Eligibility for an exemption from the individual mandate to enroll in health insurance

After applying for healthcare through a state Exchange, consumers will receive a letter explaining what programs for which they qualify, including eligibility for Medicaid or CHIP. The letter will provide information on how to file an appeal, the deadline for the appeal, how to get free help filing an appeal, and how to receive appeal information in a language other than English. This information will be included for each individual family member that applied for coverage.

The majority of appeals will need to be filed with the exchange directly, but appeals to decisions regarding Medicaid and CHIP may need to be addressed to the government offices administering those programs. The eligibility notice will provide specific contact information for the appeals process.

Appeals can be filed online under the same account used to purchase health insurance on an exchange. Filing methods are also available over the phone or through the mail.

After the appeal has been received, the applicant will be sent a letter that acknowledges their appeal and provides more information on the appeals process.

Applicants that need assistance in filing an appeal have several options. Navigators can provide free help in filling out needed forms or can refer consumers to an appropriate organization. Consumers have the right to authorize another family member, friend, attorney or another person to represent them during the appeals process. Information about appeals or other aspects of the exchange is available in non-English languages at no extra charge.

During the appeals process, an applicant may be asked to provide more information, including copies of certain documents relating to income or other materials. Providing supplemental materials in a timely manner may result in a faster appeals process. Consumers may retain their eligibility status while they appeal a decision and will receive information explaining their options for doing so.

Decisions on appeals will generally be made within 90 days. Appeal results will be sent via mail and an explanation of the decision will be provided.


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