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How to file an appeal at healthcare.gov ACA Marketplace

If you are a client of Hummingbird and you have received a decision or that something with your application/account is wrong from the healthcare.gov ACA Marketplace that you disagree with, you have the right to appeal.

Here are the steps on how to appeal a healthcare.gov ACA Marketplace decision:
  1. Check the deadline. You generally have 90 days from the date of the decision to file an appeal.
  2. Gather your evidence. Gather any evidence that supports your appeal, such as medical records, letters from doctors or other healthcare providers, or other documentation.
  3. Write your explanation for the appeal. Your explanation should be a concise synopsis of why you disagree with the decision and why you believe the decision should be reversed. Be sure to include all of the main details in your explanation; oftentimes, a bullet point list is the simplest way to achieve this.
  4. File your appeal. You can file your appeal online, by mail, or by fax. Further instructions and direct links are below.  Online appeals are typically the easiest and quickest way; there is a fillable PDF form with DocuSign electronic signatures included.  If you choose online, make sure to download a copy of the appeal BEFORE you submit it.
If you need help filing an appeal, you can contact your Hummingbird agent for assistance. Also, you are welcome to include your agent as an Authorized Representative on the appeal – if this is done, the Marketplace will usually communicate directly with your agent on the matter, and your agent will communicate with you to ensure all important details are correct to ensure the smoothest appeal process.  You will need to let your agent know you are doing this, so that we are aware and watching for anything from the Health Insurance Marketplace, or healthcare.gov.  If you choose to appoint your agent as your Authorized Representative please be sure to use this address information (4 Vermont Ave, Suite 2, Asheville, NC 28806) and include your agent’s direct phone number and email address, as well.
Here is the link for the website to begin the appeal process: https://www.healthcare.gov/marketplace-appeals/what-you-can-appeal/
Marketplace decisions you can appeal:
If the Marketplace said you aren’t eligible to:
  • Buy a Marketplace plan or a Catastrophic plan.
  • Get financial help with Marketplace costs or you disagree with the amount of financial help you qualify for.
  • Enroll in or change your Marketplace plan with a Special Enrollment Period.
  • Get an exemption from the requirement to have health insurance.
You can also appeal:
  • If the Marketplace didn’t let you know your eligibility results soon enough.
  • The date your Marketplace coverage started.
  • Other decisions if you live in certain states.
Marketplace decisions you can’t appeal
You disagree with:
  • The date the Marketplace ended your coverage.
  • Information on your Form 1095-A, or you want a corrected form.
Your health insurance company:
You also can’t appeal if you:
  • Want to change information on your Marketplace application.
  • Filed your federal income tax return and have to pay back some or all of the premium tax credits you used during the year to lower your monthly premiums.
  • Applied for coverage through an employer in the SHOP Marketplace. But, you can file a SHOP employee complaint.
Appealing after 90 days
If you miss the 90 day timeframe to file an appeal, you may be able to get an extension. When you file your appeal, explain the reason why you missed the deadline in your appeal request.
What to know about appeals
  • You can ask for a faster appeal if your health is at risk. (Like if you’re currently in the hospital or urgently need medication.)
  • You can represent yourself or appoint a representative to help you with your appeal. That person can be a friend, relative, lawyer, or other person.
  • If you missed the 90-day deadline, explain the reason why in your appeal request. You may be able to get an extension.
  • The outcome of an appeal could impact coverage for other members of your household.
  • If you have coverage, stay enrolled and pay your premiums during your appeal. If you drop or lose your coverage during your appeal, you might have to wait to re-enroll (even if your appeal is successful).
Note: The Marketplace will mail you (or your Authorized Representative) a letter telling you if you’re eligible to keep your coverage and continue to get financial help during your appeal. If you get tax credits during your appeal and your appeal is unsuccessful, you’ll have to pay back the tax credits you got during your appeal when you file your federal income tax return.
Thank you for your continued business, and we are here to support you anytime you need it.