How To Appeal a Marketplace Decision

If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal.

You generally have 90 days from the date of your Eligibility Notice to ask for an appeal.

Marketplace decisions you can appeal:

The Marketplace Appeals Center can review these types of issues:

  • Not eligible for advance payments of the premium tax credit (APTC)
  • Eligible for APTC, but the amount is wrong
  • Not eligible for a Special Enrollment Period
  • Not eligible to buy a Marketplace plan
  • Not eligible to choose a Catastrophic plan
  • Not eligible for an exemption from the requirement to have health insurance
  • If you live in Alabama, Alaska, Louisiana, Montana, New Jersey, Virginia, West Virginia or Wyoming, you can also appeal a denial of Medicaid or CHIP eligibility

You can’t file an appeal until you get an Eligibility Determination Notice that says your eligibility for coverage has ended or your savings have changed. That notice will also describe your appeal rights. Learn more about when the Marketplace needs documents to confirm information from your application.

Decisions you can’t appeal through the Marketplace

The Marketplace Appeals Center can’t review these types of issues:

  • You disagree with the date the Marketplace ended your coverage.
  • Your health plan company didn’t apply your premium tax credits correctly.
  • You want to change information on your Marketplace application.
  • You believe your health plan owes you a refund.
  • You want to end your health plan on an earlier date.
  • You disagree with information on your Form 1095-A, or want a corrected form.
  • Your health plan refuses to pay a claim you think should be covered.
  • When you filed your federal income tax return, you owed back some or all of the premium tax credits you used during the year to lower your monthly premiums.

If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. Learn how to appeal a health plan decision.

Appealing after 90 days

If you miss the 90 day timeframe to file an appeal, you may be able to get a “good cause” extension. If you missed the 90-day deadline, explain the reason why in Step 3 of the Appeals Form or in your appeal request letter.