This Health Reform: Beyond the Basics webinar was presented in partnership with the National Health Law Program on February 16, 2021. Mara Youdelman, Managing Attorney at the National Health Law Program, provided information on marketplace appeals, detailing what decisions can be appealed, how to file an appeal, and ways to expedite the appeal process.

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Overview of Marketplace Eligibility Appeals

What Determinations Can Be Appealed

• CMS Casework
• Insurer Appeals
• State Department of Insurance Appeals
• Marketplace Appeals
• SBM Appeals to FAE
• When a Consumer Can Appeal
• Examples

How to Request an Appeal

• Requesting a Marketplace Eligibility Appeal
• Timeframes for Requesting Appeals
• Requesting to Continue Tax Credits During an Appeal
• Who Can Assist in an Appeal
• Role of Assisters in the Appeals Process
• Examples

Appeals Process & Implementing Eligibility Decision

• First Stage of an Appeal: Informal Resolution
• Second Stage of the Appeal: Formal Resolution/Hearing
• Expedited Appeals
• Eligibility Appeals Decisions
• Implementing the Eligibility Appeals Decision
• Examples

This Health Reform: Beyond the Basics webinar was presented in partnership with the National Health Law Program on February 25, 2020. Mara Youdelman, Managing Attorney at the National Health Law Program, provided information on marketplace appeals, detailing what decisions can be appealed, how to file an appeal, and ways to expedite the appeal process.

↓ View Presentation Slides (PDF)

Watch the Webinar

Additional Resources

Beyond the Basics Webinar Series | View all webinars

Tools and Resources | View all tools and resources

Frequently Asked Questions | View FAQs

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

↓ View presentation slides (PDF) 

Watch the Webinar

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