Helping Clients with Marketplace Eligibility Appeals

Saving money and having an affordable insurance option is a priority of the federally facilitated marketplace. The marketplace accepts appeals from individuals who may disagree with a decision that was made about their eligibility. These appeals can be filed up to 90 days after receiving an eligibility notification.

An appeal can give clients another opportunity to apply for a marketplace plan if they are eligible, receive subsidies, or get an exemption.

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Decisions That Can Be Appealed

There are select decisions that are made by the marketplace that can be appealed. If your client receives a notification about any of the following determinations and they disagree, consider filing an appeal.

• The marketplace determined your client cannot purchase a marketplace plan
• They were found ineligible for subsidies or were eligible for more subsidies than they were given
• They were found ineligible for a Special Enrollment Period (SEP)
• They were found ineligible for an exemption to apply for catastrophic coverage
• The marketplace didn’t let you know of their eligibility results soon enough
• The date their coverage started

Note: some states allow individuals to appeal decisions related to CHIP.

Decisions That Cannot Be Appealed

Unfortunately, some decisions are more set in stone. Remind clients that although they may disagree, the marketplace does not consider appeals for the following:

• Any tax-related information
• End-of-coverage date set by the marketplace
• Incorrectly applied subsidies

To dispute any decisions made about coverages, encourage your client to contact their insurance carrier. The federal marketplace does not make resolutions about what is covered beyond the 10 essential benefits. Be mindful that the marketplace requirements are set to establish boundaries between the marketplace, agents, and consumers.

It’s also imperative to stay on top of appeal deadlines. When your client receives their eligibility notice, they must stay on top of communications with the marketplace. Anything that has occurred after 90 days of receiving the eligibility notice is not able to be appealed. If your client has missed the deadline to file an appeal, consider if an extension request is necessary. The marketplace will decide if they will grant your client an extension or not. We’ll give you an overview of how to file an appeal with the marketplace if your client is eligible to submit one.

If your client has missed the deadline to file an appeal, consider if an extension request is necessary.

Appeal Process Overview

The following procedures and appeals are only applicable for the federal marketplace. If you are selling plans in a state-based exchange, consult your individual state’s marketplace if you’d like to make an appeal. Be mindful that the timeline to submit an appeal in a state exchange is shorter at only 30 days.

As a client’s agent, if you are recorded as the individual’s authorized representative, you can complete the appeal on their behalf.

Even if you are appointed on their marketplace application, the client must still select you as their authorized representative to assist with the appeal. This can be done when filing the original appeal request either online or on paper. Your client can also write a letter to the Marketplace Appeals Center.

This letter must include:

• Your client’s name, address, and phone number
• Their appeal number (if they have one)
• A statement appointing you as their representative
• Your name, address, and phone number
• A statement allowing the Marketplace Appeals Center to discuss your client’s appeal with you
• Your client’s signature and the date your client signed the request

If your client does submit authorization for you to act as their representative, it may be revoked by your client at any time by contacting the Marketplace Appeals Center at 1-855-231-1751.

Any additional information that is included in the appeal can be useful for the marketplace. If your client requires an expedited appeal for health reasons, please note this in the initial filing. Encourage your clients to respond to additional requests and submit documentation quickly. Timely and complete communications are the easiest way to have your appeal granted.

Timely and complete communications are the easiest way to have your appeal granted.

There will be an appeal number assigned to their case, this number is important to note because all correspondence that connects with this appeal will be noted with this appeal number. All documentation that is submitted should include this number.

The marketplace also provides support for clients who may not speak English.

Your Role As Their Agent

As your client’s representative and trusted agent, you are responsible for carrying out marketplace appeals on their behalf. You are held accountable for providing information and documentation in a timely manner to best support your client.

Additionally, you are liable for returning phone calls from the marketplace, attending conference meetings, or any hearings that the marketplace may hold. Keep a record of all communications and attend all calls, meetings, or hearings to make any claims or presentations that may benefit your client.

Once an appeal decision has been made, inform your client of the verdict. They may need to make a decision about their coverage or plan. After they have made a selection, you will be the one to submit any information on their behalf.

It’s a big responsibility to be the authorized representative in the appeal process. Understand what this process requires you to do and ensure that you can act responsibly to best assist your client. After the appeal has been submitted, there are more steps to follow along with as their agent. We’ll talk about what to pay close attention to.

What to Expect After Filing an Appeal

After you have successfully submitted your client’s marketplace appeal, they’ll receive a letter in the mail confirming receipt. If this letter notes that the appeal request is invalid, your client will receive notification that they may need to submit more information or seek further assistance.

You or your client may also be contacted by phone if the marketplace needs more information. Act quickly on these requests because they can affect the timeliness of the final decision.

Encourage your clients to utilize their HealthCare.gov account or HealthSherpa. You can track all forms that have been filed and received through these platforms.

At HealthCare.gov:

1. Log in
2. Select your current application
3. Select eligibility and appeals and then choose file new appeal or check appeal’s status

There are five stages to which appeals are resolved:

• Appeal submitted: The appeal has been received by the marketplace.
• In review: The appeal is being reviewed as well as any documentation that was also submitted.
• Informal resolution: Following the marketplace’s initial review, the marketplace will follow up if there are any unanswered questions or if additional documentation is required. A letter will then be sent that will be marked “informal resolution” with the results of the appeal.
• Hearing: If your client disagrees with the initial informal resolution results, a hearing can be requested.
• Decision: When the appeal has a final decision, you will receive a letter noting the next steps.

Your client may be offered temporary benefits while the appeal is pending. Your client can choose to accept these or waive them. If your client accepts these benefits and then loses the appeal, they may have to pay back the benefits they weren’t eligible for. Educate your client about this once they are offered temporary benefits.

If your client is satisfied with the decision that was made during the informal resolution, this decision will be binding. However, if your client is not satisfied, a formal hearing may be requested. Some cases, due to their complexity or nature, go directly to a hearing. Your client will receive written notice of the scheduled hearing date at least 15 days prior to the hearing date. These are conducted via phone and everything in the appeal hearing is conducted under oath.

The final decision will be made within 90 days of the hearing. This final decision letter will include instructions for implementation, your client must follow these instructions. Encourage your client to watch out for any additional communications about appeal status, benefits, or possible money owed.

Be mindful that your client may be owed a refund or may owe additional money to the marketplace depending on the decision that was made.

The appeal process is very important for clients who disagree with a coverage decision or are eligible for more subsidies than they were offered. These determinations can mean the difference between affordable health care coverage or savings towards their insurance.

As an insurance agent, we know these decisions are important. That’s why at Ritter we’re committed to supporting you with sales advice and personalized recommendations, and educational resources to save you time that way you can spend more time with your clients. Register with Ritter today for free!