This is unclear. So far, the federal government has not established a clear appeals process for problems that arise under the rule that permits insurers to refuse to renew Marketplace coverage for nonpayment. It is important that you sign up for coverage before the end of Open Enrollment. At this point, options to consider include:
Ask your insurer to reconsider. Be sure to present your cancelled check or other proof that you paid.
Report this problem to the Marketplace and to your state insurance regulator and ask their help resolving the problem
Review Marketplace plan options offered by any other insurers and consider signing up for one of those if you can’t get this problem resolved before December 15.
That’s not advisable. The Marketplace will check the information you provide against a number of databases (including IRS data, Social Security data, wage databases, and others). If the information you provide is very different from what’s in these databases, you may be asked to provide additional documentation. In addition, at the end of the Application for Health Coverage and Help Paying Costs, you will have to sign that you have provided true answers to all questions to the best of your ability. Knowingly providing untrue information is against the law and could even result in civil money fines.
For the 2018 tax year, you can claim a hardship exemption directly on your tax return instead of applying to the Marketplace for a hardship exemption. If you experienced a hardship that prevented you from obtaining health insurance in 2018, you can simply check the box on the front of the federal Form 1040 indicating that you qualify for an exemption. You will not be required to submit documentation with your tax return, but should retain any documentation of the hardship for your own records.
You may be asked for additional information about your projected income. The Marketplace will compare your estimated income to other available data on your most recent income (for example, with tax return data.) If you estimate your annual income will be substantially less — by 25% or $6,000, whichever is greater — than the amount you earned in previous years the Marketplace will ask you to provide documentation to support your estimate. This may include a letter from your employer, a pay stub from your new job or other documents. In some cases, just explaining your changed circumstances may be enough.
Your employer is not required to fill out the form that asks about affordability of your job-based health plan. If for any reason you cannot obtain this information from your employer, you should report to the Marketplace what you know, yourself, about your eligibility for employer sponsored coverage, the cost of that coverage, and whether it meets minimum value. The Marketplace may try to follow up with your employer and collect or verify this information. The Marketplace will determine your eligibility for subsidies based on the information you provided or based on any information the Marketplace was able to obtain on its own through other follow up with your employer.
Although employers aren’t required to provide you this information up front, most are expected to do so. All employers are required to provide you with this information at year end. In January, your employer will be required to provide you with a Form 1095-C that indicates whether health benefits they offered to you in the prior calendar year meet the requirements for affordability and minimum value.
This will depend on the reason for your appeal and the documentation needed to decide your appeal. Contact the Marketplace for more information about your appeal.
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
Your eligibility for an exemption from the penalty for not having health insurance
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.
You can appeal the Marketplace’s decision to reduce your tax credit. Information on how to appeal will be included on the final determination notice. If your appeal is successful, your tax credit will be restored retroactively.
Generally, if the Marketplace hasn’t received the requested information within 90 days and you didn’t already ask for an extension, the Marketplace will make a determination based on the information it has.
Yes, assuming your coverage is purchased in a state that allows the tobacco surcharge. An insurer can adjust the premiums of health plans sold to small businesses based on the number of workers who use tobacco.