Can I appeal a decision made by the health insurance exchange?
Yes, you can appeal any decision made by the exchange. This includes decisions regarding your eligibility for subsidies, individual mandate exemptions, and your ability to purchase insurance through the exchange in the first place. You can also appeal the size of the subsidy that you receive and, if successful, your subsidy can be enlarged retroactively. Appeals can also be made if the exchange failed to notify you of an important change or decision in a timely manner.
If you are interested in making an appeal, start by reviewing the information in your determination notice. This can be found online or as a hard copy sent in the mail depending on how you chose to submit your information. These notices are often vague regarding why a specific decision was reached, though they will always provide instructions on what to do if you want to appeal that decision.
Those living in states that use the federal marketplace at HealthCare.gov will need to submit a written appeal. This can be done in the form of a letter or by using one of the templates available on the site. Appeals should include your name, contact information, and a description of which decision you are appealing and why. You are also allowed to submit documents that will help support your case. These can be sent in along with your initial request or at any time in the process up until a formal decision has been reached. Make sure that any documents you submit are copies and not originals.
You typically have 90 days from the date on your determination notice to request an appeal. The appeals process is not immediate, though you can request an expedited appeal if you have serious health issues and a delay could prove harmful. If you need an expedited appeal, make sure you indicate this when submitting your appeal to the exchange. If you have questions, concerns, or need assistance at any point during the process, talk to a navigator or another expert. In some areas, you may even be able to meet with such an expert in person. The exchange’s website should provide links directing you to resources in your area.
Once you have submitted your appeal, the exchange will review the information you have provided and notify you of its decision. The length of the appeals process will vary depending on the reason for the appeal, what kind of documentation is needed or provided, and whether or not you requested that it be expedited. While your appeal is still pending, you may be given the option to receive temporary benefits. You are free to accept or waive these benefits as you like – just keep in mind that you may need to pay them back should you accept them and then lose your appeals case. Contact the exchange if you have any questions or concerns about when your appeal will be reviewed.
If you are unsatisfied with the outcome of your appeal, you can request a hearing. In some cases, the exchange may ask to resolve the situation with you informally before the hearing takes place.
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