Resource from the National Health Law Program (NHeLP)
Developed as part of the Consumer Assistance Coordination Hub (CACH), the National Health Law Program developed a fact sheet for assisters that lays out the grounds for appeals and explains where individuals should go for assistance: Marketplace Casework, Complaints and Appeals.
Depending on the situation, individuals may have four options for obtaining relief:
- Request for Casework – for help with a complex case, access to certain special enrollment periods or Form 1095-A that cannot be resolved through other resources;
- Appeal to Marketplace – for help with problems related to a final Marketplace eligibility determination;
- Appeal to Insurer – for help with problems related to a decision by an insurer or participating provider in a health plan; and
- Complaint to Department of Insurance – for help with problems related to an insurer’s decision, discrimination by an insurer, or fraudulent selling of insurance.
The fact sheet breaks down what situations and issues are appropriate for each process.