Marketplace eligibility appeals: subsidies, enrollment and coverage

What you can appeal

• You can appeal decisions about whether you can buy a Marketplace plan, the amount of financial help, a special enrollment period, an exemption, the date your coverage started, and a Marketplace that did not tell you its decision in time. You cannot appeal the date the Marketplace ended your coverage or what is on your Form 1095-A. If your insurance company refuses to pay a claim or ends your coverage, appeal to the insurance company instead.

Law: 45 CFR 155.505(b); HealthCare.gov, What can I appeal?

The deadline and how to appeal

• You generally have 90 days from the date of your Eligibility Notice to appeal. If you are late, explain why when you file; you may be able to get an extension.

  Law: 45 CFR 155.520(b), (d)(2)(i)(D); HealthCare.gov, What can I appeal?

• The Marketplace must accept appeals by phone, mail, online, and in person where available. For HealthCare.gov states: Marketplace Appeals Center, PO Box 311, Pittston, PA 18640; secure fax 1-877-369-0129; phone 1-855-231-1751 (TTY 711). States with their own Marketplace have their own appeal process.

  Law: 45 CFR 155.520(a); HealthCare.gov, Getting help with your appeal

Faster decisions and the decision itself

• You can ask for a faster (expedited) appeal if waiting could seriously put your health at risk. Explain the health reason when you file.

  Law: 45 CFR 155.540; HealthCare.gov, Getting a faster appeal

• The appeals entity must send a written decision within 90 days of receiving a valid appeal, as administratively feasible. If a state Marketplace appeal goes against you, you can appeal to HHS within 30 days.

  Law: 45 CFR 155.545(b)(1); 45 CFR 155.520(c)

Keeping coverage and your records

• If you are eligible, stay enrolled and keep paying premiums during your appeal. If you get premium tax credits during the appeal and lose, you may have to pay them back at tax time.

  Law: HealthCare.gov, How do I file an appeal?; 45 CFR 155.520(d)(1)(i)(B)

• To get the documents in your appeal case, call the Marketplace Appeals Center at 1-855-231-1751 or use its appeal record request form.

  Law: HealthCare.gov, What happens after I file an appeal?

Marketplace plans and Medicaid

• Decisions by the Health Insurance Marketplace about whether you can buy a plan or get financial help are appealed to the Marketplace, not to the insurance company. A refused claim from a Marketplace plan is appealed to the insurance company.

  Law: 45 CFR 155.505(b); HealthCare.gov, What can I appeal?

• Medicaid works differently. You appeal a Medicaid denial, cut or end of coverage by asking for a state fair hearing. If you are in a Medicaid managed care plan, you usually appeal to the plan first.

  Law: 42 CFR 431.220-431.221; 42 CFR 438.402, 438.408

States with their own Marketplace appeal

• California: 90 days
• Colorado: 60 days
• Connecticut: 90 days
• District of Columbia: 90 days
• Georgia: 90 days
• Idaho: 30 days
• Illinois: 90 days
• Kentucky: 30 days
• Maine: 90 days
• Maryland: 90 days
• Massachusetts: 60 days
• Minnesota: 90 days
• Nevada: 90 days
• New Jersey: 90 days
• New Mexico: 90 days
• New York: 60 days
• Pennsylvania: 90 days
• Rhode Island: 30 days
• Vermont: 90 days
• Virginia: 90 days
• Washington: 90 days

More →

Before you act

Keep your eligibility notice and the date you got it. Check the deadline in the notice before you do anything else.

Quick answers

Free help

Free help can look at your denial and your letters. Consumer assistance programs, legal aid groups and state insurance departments do not charge for this.

• Your state's Consumer Assistance Program (CAP) or insurance department
• U.S. Department of Labor, Employee Benefits Security Administration (EBSA) · 1-866-444-3272
• HealthCare.gov Marketplace Call Center and local help · 1-800-318-2596
• CCIIO Health Insurance Assistance Team · 1-888-393-2789
• Legal Services Corporation (LSC) - Find legal aid
• LawHelp.org
• LawHelp.org

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