In this Health Reform: Beyond the Basics webinar presented in partnership with the National Health Law Program (NHeLP) on February 28, 2018, Mara Youdelman, Managing Attorney of NHeLP’s DC office, provides information on marketplace appeals, detailing what decisions can be appealed, how to file an appeal, and ways to expedite the appeal process.

Presentation Slides

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Overview

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National Health Law Program (NHeLP)

General process for Marketplace eligibility appeals (video section, slides)

What Determinations Can Be Appealed

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Not all issues can be appealed to the Federal Appeals Entity (FAE) (video section, slides)

• When to ask the Marketplace Call Center to submit casework
• When to appeal with the insurer
• When to file a complaint with the state Department of Insurance (DOI)

Marketplace appeals (video section, slides)

• When to appeal to the FAE or a State-Based Marketplace (SBM)
• Appealing a SBM determination to the FAE
• Timing of when a determination can be appealed
• Example: What can be appealed?
• Example: “Temporary” eligibility determination

How to Request an Appeal

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Requesting a marketplace eligibility appeal

• Timeframes for requesting appeals
• Process once appeal is received

Authorized representatives for an appeal (video section, slides)

• Role of navigators in the appeals process
• Example: Authorized representative

Appeals Process and Implementing Eligibility Decision

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Stages of an appeal:

• First stage: Informal resolution
• Second stage: Formal hearing and resolution

Expedited appeals

• Example: Expedited appeal

Eligibility appeals decision (video section, slides)

• Implementing the eligibility appeals decision
• Example: Retroactive coverage
• Example: Family glitch

Contact information for help with appeals

Key points to remember (video section, slides)

Q&A

ACA Exemption Tool

Presented by Tara Straw, Senior Policy Analyst at CBPP

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Interactive tool to determine some of the most common ACA exemptions based on income:

• Income below the filing threshold
• Income below 138% FPL (in non-expansion states)
• Unaffordable coverage at work
• Unaffordable coverage in the Marketplace

View ACA Exemptions Related to Income Tool

Additional Resources

Resources | View resources links

NHeLP: Marketplace Appeals Fact Sheet | View fact sheet

ACA Exemptions Related to Income Tool | View tool

Beyond the Basics Webinar Series | View all webinars

Key Facts About Health Reform | View all key facts

Tools and Resources | View all tools and resources

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.

↓ View Marketplace Casework, Complaints and Appeals

Developed as part of the Consumer Assistance Coordination Hub (CACH), the National Association of Health Access Assisters developed a resource for assisters: Incorporating Volunteers into Outreach and Enrollment Work.

This resource outlines how enrollment assister organizations can utilize volunteers to help spread the word and ensure people enroll in coverage to make the most of this open enrollment period.

↓ View Incorporating Volunteers into Outreach and Enrollment Work

In this special webinar presented on October 24, 2017, Karl Cooper, Director of Public Health Programs at the American Association on Health and Disability (AAHD), helps you think about what questions a person with a disability needs to think about when they are considering their health care options in the Marketplace and provides an introduction to the resources available through the National Disability Navigator Resource Collaborative (NDNRC). Additionally, it addresses disability etiquette and basic accessibility considerations for anyone doing enrollment work.

Presentation Slides

↓ View presentation slides (PDF)

Watch the Webinar

Overview

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• AAHD mission
• Health disparities for people with disabilities
• Disability law and the Affordable Care Act

National Disability Navigator Resource Collaborative (NDNRC)

Jump to video section, View slides | Find out more

• Overview of resources available through NDNRC
• Resource: Guide to Disability for Health Insurance Navigators
• Resource: Topical and population-specific fact sheets
• Community Outreach Collaboratives

Considerations When Assessing Health Options

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Health Insurance Jeopardy: It’s not about the answer. It’s about asking the right question!

• Topical questions
• Population specific questions
• Disability etiquette
• Resource: Health Insurance Jeopardy Series | View NDNRC YouTube channel

Ongoing Challenges

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• Limited provider networks
• Limited formularies
• Discriminatory pharmacy design
• Plan transparency
• High out-of-pocket costs
• Confusion on the definition of “rehabilitation” and “habilitation” services and supports
• Confusion on the coverage of prosthetic devices and durable medical equipment
• Confusion about coordinating exchange coverage with Medicare and Medicaid
• Delays in getting plan information once they are enrolled
• Communication Issues for deaf and hard of hearing

Disability Etiquette

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• People with all types of disabilities
• People with mobility disabilities
• People who are blind or low vision
• People who are deaf or hard of hearing
• People with speech and language disorders
• People with cognitive or intellectual disabilities
• People with mental health or behavioral health disabilities
• Disability accessibility and accommodations

Q&A

Additional Resources

Resources links | View resource links

American Association on Health and Disability (AAHD) | Find out more

AAHD | National Disability Navigator Resource Collaborative (NDNRC) | Find out more

AAHD | NDNRC: Guide to Disability for Health Insurance Navigators | View guide

AAHD | NDNRC: Topical and population-specific fact sheets | View fact sheets

AAHD | NDNRC: Health Insurance Jeopardy Series | View NDNRC YouTube channel

Beyond the Basics Webinar Series | View all webinars

Key Facts About Health Reform | View all key facts

Developed as part of the Consumer Assistance Coordination Hub (CACH), the National Immigration Law Center developed a resource for assisters: Tips for Addressing Immigrant Families’ Concerns When Applying for Health Coverage Programs.

This resource includes suggestions on how to address concerns when talking to families, information on protections for household members not applying for coverage, and lists additional resources.

↓ View Tips for Addressing Immigrant Families’ Concerns When Applying for Health Coverage Programs