How to Appeal an ACA Marketplace Decision in Florida
If the Marketplace tells you that you do not qualify for a plan, a subsidy, or a Special Enrollment Period, that decision is not always final. You have the right to ask for a review. This guide explains which decisions can be appealed, the deadline, and what to expect, based on current HealthCare.gov guidance.
Which Decisions You Can Appeal
Per HealthCare.gov, you generally may appeal a Marketplace decision that says you are not eligible to buy a Marketplace plan or Catastrophic coverage, get financial help with Marketplace costs (including the amount you believe you qualify for), enroll in or change a plan using a Special Enrollment Period, or get an exemption. You can also appeal the date your coverage started or ended, or information on your Form 1095-A.
| You Can Appeal Through the Marketplace | You Cannot (Use Another Route) |
|---|---|
| Denial of eligibility to enroll | A request to change information on your application |
| Amount of financial help | Repaying premium tax credits after filing your taxes |
| Special Enrollment Period denial | An insurance company’s refusal to pay a claim or end of your coverage (appeal with your health plan) |
| Coverage start or end date | A SHOP employer application (file a SHOP employee complaint instead) |
| Errors on Form 1095-A | — |
The Deadline
You generally have 90 days from the date of your Eligibility Notice to ask for an appeal. If more than 90 days have passed, explain why you missed the deadline when you file, and you may be able to get an extension, according to HealthCare.gov.
Step by Step
- Submit requested documents first. If the Marketplace asked you to confirm information on your application, send those documents before appealing. It will issue an updated decision, and you might not need to appeal.
- Request the appeal in time. If you still disagree, file within the 90-day window. How you file depends on where you live and whether you have a Marketplace account, as noted on the HealthCare.gov appeal forms page.
- Include copies, not originals. Attach copies of documents that support your appeal and do not send original documents.
- Consider a representative. You can authorize a trusted family member, friend, advocate, or attorney to act on your behalf.
What Happens During an Appeal
- Order of review: Appeals are generally processed in the order they are received.
- Expedited appeals: You can ask for one if waiting for a standard decision may seriously put your health at risk, such as being in the hospital or needing urgent medication.
- Keep your coverage active: If you are eligible, enroll in a plan and pay your premiums during the appeal. If you drop or lose coverage, you may have to wait to re-enroll, even if your appeal succeeds.
- Repayment risk: If you receive the premium tax credit during the appeal and the appeal is unsuccessful, you will have to repay it when you file your taxes.
- Household impact: An appeal decision could affect coverage for other household members.
Need Help With Your Marketplace Application?
A licensed agent can help you review your eligibility notice, gather the right documents, and compare plans at no extra cost to you. Start with HealthSherpa, or call (212) 804-6730 to speak with a licensed agent today.
This article is for educational purposes only and does not constitute insurance, legal, or financial advice. This site and its agents are not affiliated with or endorsed by the federal government, HealthCare.gov, or the Centers for Medicare & Medicaid Services (CMS). Appeal rules and deadlines are subject to change — always verify current details at HealthCare.gov or CMS.gov. This content is provided by a licensed agent affiliated with Flatbush Insurance Brokerage.
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