Appeals and Exemptions

July 18, 2014 at 2:48 PM

               Navigators are able to continue assisting consumers outside of Open Enrollment periods in several ways:  Education, Medicaid/CHIP applications, Special Enrollment Periods (SEPs), and Reportable Changes (RCs).  Today’s article looks at appeals and exemptions as two more avenues of Navigator assistance; includes examples of when they can each be used; and provides an overview of the appeals process.

               An appeals process is in place for any initial Marketplace decision.  The most common examples of reasons for pursuing decision appeals, include:

  • Eligibility to purchase a plan through the Marketplace
  • Ability to purchase a Marketplace plan outside of Open Enrollment
  • Amounts of Premium Tax Credits (PTCs) and Cost Sharing Reductions (CSRs)
  • Determinations based on assumed Medicaid/CHIP eligibilities
  • Eligibility for exemption from shared responsibility payment

Each Marketplace decision comes with a 90-day deadline for filing an appeal; with the specific date detailed in the eligibility determination.

               There are two methods for requesting an appeal of a Marketplace decision should a consumer elect to pursue one:  write a letter or complete an appeal request form.  When completing an appeal request form, consumers must make sure to submit the correct form for their state of residence.  A direct link to the form for Indiana residents can be found here

               Once the Marketplace has received and processed the consumer’s appeal request, a confirmation and further instructions will be sent to the consumer.  An informal resolution will be provided to the consumer once all of the information is reviewed.  If the consumer agrees with the resolution, the decision will be implemented and the appeal will be closed.  If the consumer does not agree, the appeal will continue to a hearing, and the final decision is mailed to the consumer.

               Whereas appeals are handled completely through the Marketplace, exemptions from the requirement to have insurance that meets minimum essential coverage (MEC) can be obtained through either the Marketplace or the IRS; depending on the exemption.  The majority of exemptions are obtainable when consumers file their tax returns.  These types of exemptions include: not meeting minimum tax filing thresholds, inability to obtain affordable coverage, short-term gaps in coverage, undocumented immigrant status, members of both healthcare sharing ministries and recognized Indian tribes, and those that are incarcerated. 

               A Marketplace certificate of exemption is only required of those applying based on hardship or religious objection.  Consumers will receive letters informing them of their exemption which will contain an exemption certificate number (ECN).  They will be required to provide the ECN when they file their taxes.  Therefore, although consumers may request an exemption at any time during the year, it is recommended that they do so with enough time to allow processing before they file their taxes.


Anyone with questions about appeals, exemptions, or any ACA related topic

is encouraged to contact an ASPIN Health Navigator by calling


Tags: Special enrollment period Appeals Exemptions Reportable Changes
Category: Marketplace

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