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Appealing a Marketplace Eligibility Determination

Appealing a Marketplace Eligibility Determination

If you do not agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal.

What You Should Know

    • Eligibility to buy a Marketplace qualified health plan (QHP), including a catastrophic plan

    • Eligibility for lower costs, including the amount of advance payments of premium tax credit or cost-sharing reductions

    • Eligibility for a special enrollment period to enroll in a Marketplace QHP outside the regular open enrollment period

    • The Marketplace eligibility decision must be “final” before an appeal is submitted.

    • The appeal must be received within 90 days of the contested Marketplace eligibility decision.

    • The request for appeal must be about a matter that is eligible for a Marketplace appeal.

    • The appeal must be requested by a consumer or by an authorized representative appointed in writing by the consumer.

    • If the appeal request does not meet these requirements, the consumer will get a notice explaining why the request is invalid and how to fix the problem and resubmit the appeal.

  • Consumers can file a request for an expedited appeal. Requests to expedite the appeal should explain how a standard appeal would jeopardize their life, health, or ability to attain, maintain, or regain maximum function.

    The request to expedite your appeal will be processed as quickly as possible. A final decision must be made as quickly as your situation requires.

    • Informal Resolution:

      • If possible, the MAC will try to resolve the appeal based on the available information.

      • This decision will be binding if the consumer is satisfied.

    • Hearing:

      • In some cases, the appeal may go straight to a hearing.

      • If the consumer is dissatisfied with the informal resolution, a hearing may be requested.

  • For questions related to the appeals process:

    • Call the Marketplace Call Center at 800-318-2596

    For questions related to an appeal that has been submitted:

    • Call the Marketplace Appeals Center at 855-231-1751 or TTY users 855-739-2231