Can I appeal a Marketplace decision?
If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal.
Decisions you can appeal
You can appeal the following kinds of Marketplace decisions:
- Whether you’re eligible to buy a Marketplace plan
- Whether you can enroll in a Marketplace plan outside the regular open enrollment period
- Whether you’re eligible for lower costs based on your income
- The amount of savings you’re eligible for
- Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
- Whether you are eligible for an exemption from the individual responsibility requirement
Your eligibility notice
When you apply for coverage in the Marketplace, you’ll get an eligibility notice that explains what you qualify for. It will provide appeals instructions for each person in your household, including the number of days you have to file an appeal.
Here’s important information to consider when planning an appeal:
- You can have someone else file or participate in your appeal. That person can be a friend, relative, lawyer, or other person. Or you can handle the appeal yourself.
- If you file an appeal, you may be able to keep your eligibility for coverage while your appeal is pending. You’ll get a letter that describes your options.
- The outcome of an appeal could change the eligibility of other members of your household.
Depending on your state and your eligibility results, you may be able to appeal through the Marketplace. Or you may have to file an appeal with your state Medicaid or CHIP agency. Your letter will explain.
2 ways to file Marketplace appeals
Your eligibility determination letter will explain how to file an appeal. In general, you can appeal your eligibility results 2 ways:
- Write a letter to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
- Mail in an appeal request form, using the proper form below:
- New Jersey
- West Virginia
- New Hampshire
- New Mexico
- North Carolina
- North Dakota
- South Carolina
- South Dakota
Appeal Request Form for the following states (Use this form only after you’ve used up all of your eligibility rights with your state):
- District of Columbia
- New York
- Rhode Island
After you file an appeal
You’ll get a letter that:
- States that your appeal request was received
- Provides a description of the appeals process
- Includes instructions for submitting additional material for consideration, if necessary
While your appeal is being processed
You may get a letter from us asking for more information or documentation, like a copy of a passport. If you send this information to us, we may be able to informally resolve your case fairly quickly.
In general, we must tell you our decision and mail our response within 90 days of when we received your appeal request.
You can file a request for an expedited (faster) appeal if the time needed for the standard appeal process would jeopardize your life or your ability to attain, maintain, or regain maximum function.
Your request to expedite your appeal should specifically explain how a standard appeal would jeopardize your life or your ability to attain, maintain, or regain maximum function.
Your request to expedite your appeal will be processed as quickly as possible. A final decision must be made as quickly as your situation requires.
Getting help filing an appeal
Navigators may assist you in filing an appeal and may answer questions about the appeals process. A Navigator is someone who can provide unbiased help when you submit an appeal. He or she may also refer you to another person or organization that can help you. Find a Navigator in your area.
You can also appoint an authorized representative to help you. Your representative can be a family member, friend, advocate, attorney, or someone else who will act for you.
How to appoint a representative to handle your appeal
You can appoint a representative either of 2 ways:
- Complete an “Appointment of Representative” form. These forms will be available soon.
Submit a written request with your appeal. Be sure to include:
- Your name, address, and phone number
- Your (case/record/request/file) number
- A statement appointing someone as your representative
- The name, address, and phone number of your representative
- The professional status of your representative or their relationship to you
- A statement authorizing the release of your personal and identifiable information to your representative
- A statement explaining why you’re being represented
- Your representative’s signature and the date they signed the request
Getting help in a language other than English
You have the right to get help and information about appeals and other Marketplace issues in your language at no cost. To talk to an interpreter, call 1-800-318-2596.
How to appeal a SHOP Marketplace decision
Learn about appealing a decision about the SHOP Marketplace for small businesses.
If you would like more information on filing an eligibility appeal you can call 1-800-318-2596 or (TTY: 1-855-889-4325).