A Marketplace notice that cuts your savings or says you're not eligible can upend your budget fast. You can appeal a Marketplace decision online through your Marketplace account, or by mail or fax. The deadline is generally 90 days from the date on your eligibility notice. A faster review exists if waiting could seriously harm your health.
The Health Insurance Marketplace is where people buy coverage under the Affordable Care Act (ACA). HealthCare.gov runs it for most states, and some states run their own. This guide covers the federal process and notes where state Marketplaces differ.
Which Marketplace decisions can I appeal?
You can appeal most decisions the Marketplace makes about your eligibility. HealthCare.gov lists what you can and can't appeal. The main ones are:
- Whether you can buy a Marketplace plan at all. This is the "Marketplace said I'm not eligible" notice.
- Whether you qualify for savings, and how much. Savings include the premium tax credit, which lowers your monthly premium, and cost-sharing reductions, which lower your deductibles and copays.
- Whether you qualify for a special enrollment period. This is a window outside Open Enrollment (the yearly sign-up period). It lets you sign up after a life change, like losing job-based coverage or moving.
Read the reason on your notice first. It shows what information the Marketplace used. Often, the appeal comes down to showing them what they didn't have.
Which decisions can't I appeal, and where do I go instead?
Some problems look like Marketplace decisions but go through a different door. A Marketplace appeal won't change these:
- The date your coverage ended. Call the Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325), as listed on HealthCare.gov. Ask how the date was set and what can be corrected.
- Information on your Form 1095-A. This is the tax form the Marketplace sends each year showing your coverage and savings. If it's wrong, call the Marketplace Call Center and ask for a corrected form.
- Paying back premium tax credits at tax time. Your savings during the year were based on estimated income. If that doesn't match your final income, you settle the difference on Form 8962 with your federal tax return. The IRS handles this, and its Form 8962 instructions on IRS.gov explain it. If you owe and can't pay in full, read how IRS payment plan options work.
- An insurance company denying a medical claim. Your plan handles that through its own appeal process, not the Marketplace. Our guide on responding to an insurance coverage denial letter walks through it.
What's the deadline to appeal a Marketplace decision?
You generally have 90 days from the date printed on your eligibility notice. The clock starts on that date, not the day the letter reached your mailbox.
Write down the notice date and your deadline somewhere you'll see them. If your state runs its own Marketplace, its deadline may be different, and your notice will tell you what it is.
How do I appeal a Marketplace decision, step by step?
- Find your eligibility notice. Note the date, the decision, and the reason given. Keep a copy.
- Gather proof. Pull documents that show what the notice got wrong. Common examples are pay stubs, a tax return, a lease showing a move, or a letter showing when job coverage ended.
- Choose how to file. You can request an appeal online through your Marketplace account. You can also get the appeal request form from the HealthCare.gov Marketplace appeals page, then mail or fax it. That page lists where to send it.
- Explain what you disagree with. Name the decision you're appealing and say why it's wrong. Plain words are fine. Include a copy of your notice and your proof.
- Keep records. Save a copy of everything you send, along with fax confirmations and mailing receipts.
- Watch your mail and phone. The Marketplace Appeals Center will contact you. Answering quickly keeps your appeal moving.
Say your job-based coverage ended in June, and your notice says you don't qualify for a special enrollment period. A letter from your employer showing your last day of coverage is exactly the proof that belongs in step 2.
You can also get help filing at no cost from trained assisters in your community. Find free local help through HealthCare.gov.
Can I get a faster appeal if my health can't wait?
You can ask for one if waiting for a standard appeal could seriously harm your health. This is called an expedited appeal. Ask for it when you file, and explain why the timing matters, like a treatment or prescription you can't afford without coverage. A short letter from your doctor helps make the reason clear.
If the faster review isn't granted, ask the Appeals Center what happens next with your request. The federal rules for Marketplace appeals are published on eCFR, and the HealthCare.gov appeals page explains the current process in plain terms.
What if my state runs its own Marketplace?
Some states run their own Marketplace instead of using HealthCare.gov. If yours does, its appeal process, forms, and deadlines may differ from the federal ones.
Look at the top of your eligibility notice to see which Marketplace sent it. If it came from your state's Marketplace, follow the appeal instructions in that notice or on your state Marketplace's website. If your state appeal doesn't go your way, check the decision letter for any further review you can request.
What mistakes should I avoid in a Marketplace appeal?
- Waiting until the deadline. Filing early leaves time to send more documents if the Appeals Center asks for them.
- Sending the appeal to your insurance company. Your insurer can't change a Marketplace eligibility decision. Send it to the Marketplace that sent your notice.
- Leaving out proof. A request that only says "I disagree" gives the reviewer nothing new. Attach the documents that show the correct facts.
- Skipping an application update. If the decision came from old income or household information, updating your Marketplace application may fix it sooner. You can still appeal too.
- Missing a call or letter. The Appeals Center may need more from you, and a missed message can slow your case down.
What this means for you
- Circle your deadline. Find the date on your notice and count 90 days from it.
- Match your proof to the reason. Pick documents that answer the exact reason on your notice.
- File the way that works for you. Use your Marketplace account, or mail or fax the appeal form. If you'd rather talk it through, call the Marketplace Call Center or a free local assister.
- Check for other help while you wait. Other programs may cover you in the meantime. You'll find more guides on the Turnout blog at turnout.co.
FAQ
I was denied a premium tax credit. Can I appeal that? You can. HealthCare.gov confirms you can appeal whether you qualify for the premium tax credit and how much you get. Include proof of your income and household size, like pay stubs or a tax return.
What if I was denied a special enrollment period? You can appeal that decision too. Send proof of the life change and its date, like a letter showing when job coverage ended or a lease showing your move.
The Marketplace said I'm not eligible. What should I do first? Read the reason on your notice. Then gather documents that show the correct facts and file your appeal within 90 days of the notice date.
Can I keep my coverage during a Marketplace appeal? If you're appealing a change to eligibility you already had, you may be able to keep your current eligibility while the appeal is decided. Ask about this when you file, and check the current rules on the HealthCare.gov appeals page or in the federal regulations on eCFR. If you lose the appeal, you may have to pay back extra savings when you file your taxes.
What happens at a Marketplace appeal hearing? The Appeals Center may first try to resolve your case informally. If you're not satisfied, you can ask for a hearing with a hearing officer. HealthCare.gov's appeals page explains what to expect and how to prepare.
Turnout is not a law firm and does not provide legal or tax advice.
It's your turn
An appeal is one path to coverage, and it may not be the only one. Run Turnout's free benefits scan to see which health coverage and other programs you may qualify for. It takes a few questions, and you'll know where to start.