Marketplace Eligibility AppealsMarketplace Eligibility Appeals

Eligibility Appeals Process Overview for the Federally-

Facilitated Marketplace

April 2015

Marketplace Eligibility Appeals 2

If consumers disagree with certain determinations made by the Marketplace, they have a right to ask for an appeal

This presentation is about appealing a Marketplace eligibility determination

Marketplace Eligibility Appeal RightsMarketplace Eligibility Appeal Rights

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Marketplace Eligibility Appeals 3

Consumers who disagree with a Federally-Facilitated Marketplace eligibility determination, or believe a mistake was made may appeal the following• Eligibility to enroll in a Qualified Health Plan • Eligibility for insurance affordability programs

Advanced Payment of the Premium Tax Credit Cost-Sharing Reductions

Appealing a Federally-Facilitated Marketplace Eligibility Determination

Appealing a Federally-Facilitated Marketplace Eligibility Determination

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• Eligibility for MAGI Medicaid and CHIP for states that have delegated these eligibility determinations and eligibility appeals to the Marketplace • Eligibility for a Special Enrollment Period to enroll

in a Qualified Health Plan outside the annual Open Enrollment Period• Eligibility for an exemption from the individual

shared responsibility payment

Appealing a Federally-Facilitated Marketplace Eligibility Determination (Continued)

Appealing a Federally-Facilitated Marketplace Eligibility Determination (Continued)

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• Failure of the Marketplace to provide a timely eligibility determination notice• Eligibility for a Catastrophic plan

Consumers in State-Based Marketplace states may appeal to the Federal Appeals Entity from • The decision of the State-based Marketplace

eligibility appeals entity, or • The denial by the State-based Marketplace appeals

entity of a request to vacate their appeal dismissal

Appealing a Federally-Facilitated Marketplace Eligibility Determination (Page 3)

Appealing a Federally-Facilitated Marketplace Eligibility Determination (Page 3)

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Two ways to request a Marketplace eligibility appeal 1. Complete an appeal request form

Available athttps://www.healthcare.gov/can-i-appeal-a-marketplace-decision/

2. Write a letter explaining the reason for the appeal

• Either way, mail the request to Health Insurance Marketplace465 Industrial Blvd.London, KY 40750-0061

Requesting a Marketplace Eligibility AppealRequesting a Marketplace Eligibility Appeal

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The Federal Appeals Entity (FAE)receives and determines validity of appeals requests• Received within 90 days of the contested Federally

Facilitated Marketplace eligibility determination or 30 days of a State Based Marketplace appeals decision or notice declining to vacate the dismissal of an appeal

• FAE has jurisdiction (described on slides 2 and 3)

• Appeal was requested by consumer or by designated authorized representative

If valid, appeal acknowledged and process begins

When a Marketplace Eligibility Appeal is Received

When a Marketplace Eligibility Appeal is Received

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Informal Resolution of Eligibility AppealsInformal Resolution of Eligibility Appeals

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The Federal Appeals Entity works with appellants to resolve eligibility appeals informally• Reviews facts and evidence• Phone conversation with appellants• Informal Resolution Notice

Describes proposed resolution and decision• If the appellant is satisfied, appeals decision follows

Unless appellant voluntarily withdraws the appeal • The appellant may request a hearing if unsatisfied

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Hearings are more formal• 15 day written notice• Conducted by telephone• Federal Hearing Officer presides• Appellants and any witnesses under oath

Faster process when standard timeframe “could jeopardize the appellant’s life, health or ability to attain, maintain or regain maximum functioning.” 45 CFR Section 155.540(a)

Marketplace Eligibility Appeal HearingMarketplace Eligibility Appeal Hearing

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After the hearing concludes the Hearing Officer carefully considers all evidence and testimony of the appellant and any witnesses

The Hearing Officer promulgates the eligibility appeal decision • Mailed to appellant within 90 days from the receipt

date of the appeal request or as administratively feasible

• The decision is final and binding

Eligibility Appeals Decisions Eligibility Appeals Decisions

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The decision is then implemented If the decision finds the contested eligibility

determination was incorrect• Appellant may decide to have it implemented

retroactive back as far as the date of contested eligibility determination

Eligibility Appeals Decisions, ContinuedEligibility Appeals Decisions, Continued

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Consumers can get help with Marketplace eligibility appeals• Health Insurance Marketplace Call Center – will

help by explaining how to request an appeal 1-800-318-2596 (TTY: 1-855-889-4325)

The Marketplace Appeals Center can answer appellants’ questions about their appeal• Call 1-855-231-1751 (TTY: 1-855-739-2231)

Getting Help With AppealsGetting Help With Appeals

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Navigator program – Navigators can help consumers ask for a Marketplace eligibility appeal

Appointed representative - can request a Marketplace eligibility appeal and speak for the consumer• Call the Marketplace Appeals Center for more info 1-

855-231-1751 (TTY: 1-855-739-2231)

Getting Help With Appeals, ContinuedGetting Help With Appeals, Continued

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To file an eligibility appeal with the Marketplace, consumers can write a letter or complete an appeal request form and either way, mail it

The Marketplace Appeals Center will try to resolve eligibility appeals informally

Appellants have a right to a hearing Decisions are in writing and mailed within 90 days

of the appeals request or as administratively feasible

Key Points to RememberKey Points to Remember

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