Can You Appeal an Unfavorable Decision From the Health Insurance Marketplace®?

According to the Centers for Medicare and Medicaid Services, over 8.2 million people chose a plan during the recent open enrollment period for participation in the Health Insurance Marketplace established under the Affordable Care Act. Out of those numbers, approximately 1.8 million enrollees were new to the marketplace, with about 6.4 million people renewing their coverage in Obamacare. These figures represent a 6.6 percent increase for 2021 enrollment compared to the same period in 2020. Enrollment had been declining between 2016 and 2020, and this year’s increase is all the more significant given that Pennsylvania and New Jersey had withdrawn from HealthCare.gov to establish their own state-based marketplaces. Currently, 36 states use the national exchange.
You may already know that you have the right to appeal a decision by your health insurer if they refuse to pay or claim or terminate your coverage. This right includes both an internal appeal where the insurance company reviews its decision through a grievance or appeals process, as well as an external review where an independent third party reviews the insurer’s decision.
But what about decisions made by the Marketplace, such as whether you are eligible for the tax credit to help with your premium payments? Can you appeal Marketplace decisions that you disagree with or are unhappy with? The answer is that you can appeal some decisions but not others. Here is a look at when you can appeal, when you can’t, and how to go about an appeal of a Marketplace decision.

What Marketplace decisions can you appeal?

Following is a list of issues that you can typically appeal when applying to the Health Insurance Marketplace:

• You are declared ineligible to buy a plan through the Marketplace
• You are declared ineligible for advance payments of the premium tax credit, also known as APTC
• You qualify for the APTC, but you disagree with the amount of credit they calculated for you
• You are found ineligible to apply or change coverage during a Special Enrollment Period
• You do not qualify to select a Catastrophic plan
• You are found non-exempt from the requirement to have health insurance
• You are found ineligible for Medicaid or CHIP (these denials can only be appealed through the Marketplace by residents of Alabama, Alaska, Louisiana, Montana, New Jersey, Virginia, West Virginia and Wyoming)

What Marketplace decisions can you not appeal?

Here are some of the types of issues that can’t be appealed through the Marketplace Appeals Center:

• A disagreement over the date your coverage ended
• An argument that your premium tax credits were misapplied
• Changing information on your application to the Marketplace
• Arguments over a refund you believe you are owed
• Attempts to end your health plan early
• A disagreement over the information contained in your 1095-A Health Insurance Marketplace Statement
• A Federal income tax calculation that shows you took too much in premium tax credits
• A refusal by your health insurer to pay a covered claim. This type of claim should be appealed to your health insurance company internally or externally with the help of an insurance law attorney.

How does the appeal process work?

You should receive documentation of the decision by way of an Eligibility Notice. Generally speaking, you have 90 days from the date of the notice to request your appeal, although it is possible to get an extension if you can demonstrate “good cause” for missing the deadline.
There are a couple of different ways to file your appeal. You can complete a blank form to mail or fax to the Health Insurance Marketplace, or you can follow the online prompts to file a form online that is specific to your issue.

Once you submit your request, you should receive confirmation of receipt within about a week. The Marketplace Appeals Center can either accept your appeal or deem it invalid; you’ll be notified in writing either way. A request might be deemed invalid if it is for an improper reason as defined above, if you missed the deadline for filing an appeal, if you didn’t include appropriate documentation, or for other reasons.

If your appeal is accepted, it will be reviewed by the Appeals Center in the order it is received, meaning you could have to wait some time until they get to your appeal, and even then they might request additional information. If your matter is urgent, you can ask for an expedited appeal in your initial appeal request.
Once the Appeals Center reviews your appeal, you should either receive a Notice of Informal Resolution telling you how the Appeals Center resolved your appeal, or you will be notified of your right to request a hearing. Typically, hearings are held via telephone.

Once a final decision has been reached, you’ll receive a notice telling you if you are eligible to buy a plan from the Marketplace, receive financial help through tax credits or Medicaid, etc.
You are allowed to appoint someone else, including an attorney, to serve as your authorized representative throughout the appeals process. You can also request help from a “Navigator” who is supposed to assist you and provide you with unbiased help.