Use the Marketplace Eligibility Appeal Request Form. Sign and submit it online. You can also download/print a form.
Another way to submit your appeal: Send your completed, signed paper form or a letter requesting an appeal. Include your name, address, and the reason for the appeal. If the appeal is for someone else (like a child), also include their name. If sending supporting documents, include copies— not the originals. Submit your paper form or letter to the Marketplace:
Mail: Health Insurance Marketplace
465 Industrial Boulevard
London, KY 40750-0061
It’s important to stay enrolled in your coverage and pay your premiums while your appeal is pending. If you don’t stay enrolled during your appeal, you may not be able to re-enroll in Marketplace coverage right away, even if your appeal decision changes your Marketplace eligibility. You may be eligible for continued benefits to help you stay enrolled.
If you think waiting for a standard decision may seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function, you can ask for a fast (expedited) appeal. (For example, if you’re currently in the hospital or urgently need medication.) Use the Marketplace Appeal Request Form (Step 3) to request an expedited appeal, or ask in your appeal request letter.
You can represent yourself or appoint a representative to help you with your appeal. That person can be a friend, relative, lawyer, or other person.
Depending on your reason for appeal, you may be able to keep your current eligibility for Marketplace coverage and/or any premium tax credits or cost-sharing reductions while we decide your appeal. If you’re eligible for continuing benefits, we’ll send you a notice letting you know and explaining how it works.
If you choose to continue your benefits during your appeal, keep in mind that you may be responsible for the cost of your coverage. For example, if your appeal decision finds that you aren’t eligible for all of the premium tax credit you got during your appeal, you may be required to pay back some or all of that tax credit when you file your federal tax return.