ObamaCare and Appeals – Everything You Need to Know About Expanded Appeal Rights Under the Affordable Care Act
The Affordable Care Act (ObamaCare) expanded health insurance appeal rights. Under the ACA it easy to appeal any health insurer or marketplace decision.
Specifically, you have the right to an internal and external appeal of any decision made by your insurer or the marketplace.
Here are the most important things to know about the process:
- The ACA expanded appeal rights, under the law you have the right to appeal almost any marketplace or insurance company decision.
- There is a wide array of decisions you can appeal, it can be a denial of a claim, being dropped for non-payment, or cost assistance being rejected.
- Who you appeal to depends on who issued the denial, if it is related to cost assistance and eligibility, it is probably a marketplace appeal, if it is related to payment or medical claims, it is typically your insurer.
- You generally have a short window of time in which to start the appeal process. The length of time you have depends on what type of decision you are appealing, but it can be as little as 15 days.
- A good first step is typically to call your insurer or the marketplace and/or let them know you want to appeal a decision. This will almost always be followed by completing a written request or filling out forms. When in doubt, put it in writing.
That is the basics. If you don’t agree with a decision, start the appeal process ASAP! With that said, there are more details to cover.
Below we cover your appeal rights and how to appeal a health insurance company denial or Marketplace decision. This includes how to appeal a health insurance company decision in regard to cost-sharing or coverage through internal and external appeals, how to get help appealing a Marketplace decision in regard to costs and coverage, and even how to appeal decisions from the SHOP marketplace for small business.
Keep reading to learn more about how to file a complaint, a few tips and tricks, and how the Affordable Care Act improves your rights in regard to the appeal process.
IMPORTANT: In general the most important thing to know about appeals is you have appeal rights, but you also have a window of opportunity in which to act. Always get the appeal process started ASAP, once the process is started things become much more flexible. Especially when it comes to missed payments, the window of opportunity to start the appeals process may be limited.
Appealing a Marketplace Decision
If you don’t think the Marketplace made the right decision in regard to eligibility, income, exemptions, or another factor you can file an appeal.
What Decisions Can be Appealed?
You can appeal the following kinds of Marketplace decisions:
- Whether you’re eligible to buy a Marketplace plan
- Whether you can enroll in a Marketplace plan outside the regular open enrollment period
- Whether you’re eligible for lower costs based on your income
- The amount of savings you’re eligible for
- Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
- Whether you are eligible for an exemption from the individual responsibility requirement
How to Appeal a Health Insurance Marketplace Decision
When you fill out an application with HealthCare.gov or your state’s Marketplace you’ll get a notice that explains what you qualify for and will include appeal instructions and the timeframe you have to appeal the decision. You can either file an appeal by yourself or get assistance filing an appeal from the Marketplace.
Make sure to hang on to your eligibility notice and keep in mind appeals can affect the coverage of everyone on the plan. In some states appealing a Medicaid or CHIP appeal requires contacting your state Medicaid office (as explained in your eligibility notice).
In general, you can appeal by:
- Writing a letter to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
- Mailing in an appeal request form, using the proper form.
- Faxing your appeal request to a secure fax line: 1-877-369-0130
After your appeal, you will receive a letter notifying you that your appeal was received and will explain what to do next. You may get a letter asking for more information. Typically appeals can take up to 90 days.
If you have questions, contact the Marketplace Call Center at 1-800-318-2596 / TTY: 1-855-889-4325.
How to Request an Expedited Appeal
If an appeal would jeopardize your life, health, or your ability to attain, maintain, or regain maximum function you can request an expedited appeal. If the expedited appeal is accepted the Marketplace will rush a final decision as quickly as your specific situation requires.
Appeal a SHOP Marketplace Decision
Both employers and employees have rights in regard to appealing a decision made by the SHOP marketplace. Denial of eligibility and the SHOP not responding in a timely manner can both be appealed.
You can appeal by filling out one of the forms below.
Mail your completed appeals form to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0001
An authorized representative can file an appeal for you. You may also get help in a language other than English.
Learn about appealing a decision in the SHOP Marketplace for small businesses.
Call the SHOP Small Employer Call Center at 1-800-706-7893 (TTY: 711). Monday through Friday, 9 a.m. to 7 p.m. ET. Agents and brokers helping small businesses can use this phone number too.
Appealing a Health Insurance Company Decision
Above we covered how to appeal an ObamaCare Marketplace decision below we cover how to appeal a decision by an insurer.
Your Health Insurance Appeal Rights
Before beginning the process of appealing to an insurance company, make sure you understand your following rights. You have:
(1) A right to information about why a claim or coverage has been denied;
(2) A right to see and respond to all information used in the internal appeal decision; and
(3) A right to an independent review (also called an external appeal).
ObamaCare Rapid Appeals
Under the ACA consumers can appeal insurance company decisions to an independent reviewer and receive a response in 72 hours for urgent medical situations (unlike the standard appeal process which can take much longer).
In most cases, you’ll first make an appeal to your health insurance provider and then rely only on an external appeal if your claim is denied. However, in emergency situations, you should exercise your right to a rapid external appeal immediately.
Please see the external review process below to quickly understand how the appeal process works for urgent medical situations.
The Right to Appeal
There are two different ways to appeal a decision by a health insurance company, an internal appeal, and an external appeal. In most cases, the proper course of action is to simply call your insurer and have an internal appeal done. If your claim is still denied then you move on to an external appeal of your claim. However, in emergency situations, you should take advantage of your right to a rapid appeal within 72 hours to ensure that you don’t go untreated due to a denied claim.
The information below is compiled from HealthCare.gov and is meant to allow users to find all important appeal information in one place. HealthCare.gov is the official website for the Affordable Care Act. When in doubt call the Marketplace helpline for further guidance: 1-800-318-2596 / TTY: 1-855-889-4325
Internal Appeal: Appealing a Denied Claim Through Your Insurer
What papers do I need?
What kinds of denials can be appealed?
How long does an internal appeal take?
What if my care is urgent and I need a faster decision?
External Appeal: Appealing a Denied Claim Externally
Types of denials that can go to external review
What are my rights in an external review?
How do I learn more about my state’s external review?
How long does external review take?
If my health insurance company participates in the HHS-administered external review process, how do I request an external appeal?
Can someone file an external review for me?
How much does an external review cost?
Where can I get help filing an appeal?
Contact HealthCare.gov for more information.
More Facts on the ACA: Rapid Appeals and Other Protections
Understanding the information above is important if you are facing a denial of your insurance claim or a treatment. Of course, there is a lot more to the law beyond your right to appeal, check out the other benefits of the Affordable Care Act to learn more about your benefits, rights, and protections under the law.
- Appealing an insurance company decision. HealthCare.Gov.