Marketplace Verification and Appeals

How do I appeal a Marketplace decision?

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You can request an appeal of any Marketplace decision, including decisions about

  • Your eligibility to buy coverage in the Marketplace
  • Your eligibility for, or the amount of, premium tax credits or cost sharing reductions
  • Untimely (late) notice from the Marketplace about a decision

To make your appeal, start by reviewing the Marketplace’s decision. You will have received the decision (called a determination notice) online if you initially applied online, or in the mail if you submitted a paper application. So far, in the federal Marketplace, the notice will not provide much detail to explain the reasons for the decision, but it will describe the process you should follow if you want to appeal.

If you have questions about what the notice says or if you want to appeal, consider asking for help from a Navigator or other in-person assister program.  The Marketplace website will have a link to programs in your area.

Generally you have 90 days from the date on your eligibility decision notice to request an appeal.  If you need health services right away and a delay could jeopardize your health, you can request an expedited appeal.

To request an appeal in federal Marketplace states, you’ll have to submit the appeal in writing.  You can write a letter or use appeal forms available on healthcare.gov and submit your appeal by mail or by fax.  Your written appeal should provide your name and contact information and an explanation of what you are appealing and why. If you are requesting an expedited appeal, indicate that on the form or state it in your letter.

You can submit documents to the Marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing.

The Marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back the benefits you weren’t eligible for.

The Marketplace will review your completed appeal once it is submitted. Then the Marketplace will let you know its decision.  If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the Marketplace may contact you to try to resolve the dispute informally.

While we have made every effort to provide accurate information in these FAQs, people should contact the health insurance Marketplace or Medicaid agency in their state for guidance on their specific circumstances.