Webinar OE5: Marketplace Appeals Process

Presented in Partnership with the National Health Law Program

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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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)




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