When you or your client believe the Federally Facilitated Marketplace (FFM) made an incorrect eligibility decision, you’re not stuck with it—there is a formal process to challenge that determination.
The Marketplace allows consumers to appeal certain eligibility decisions within 90 days of receiving their eligibility notice. Filing an appeal gives your client another chance to qualify for Marketplace coverage, financial assistance, or select exemptions.
What Eligibility Decisions Can Be Appealed
Your client can request an appeal if they receive a determination they disagree with, including:
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The Marketplace says they cannot enroll in a Marketplace plan.
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They’re denied subsidies or believe they qualify for more financial help than they were awarded.
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They are denied a Special Enrollment Period (SEP).
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They are denied an exemption needed to enroll in catastrophic coverage.
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The Marketplace fails to provide timely eligibility results.
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The Marketplace assigns an incorrect coverage start date.
Note: Some states also allow appeals related to Children’s Health Insurance Program (CHIP) eligibility.
What Cannot Be Appealed
Some decisions fall outside of the Marketplace appeals process. The Marketplace will not review appeals regarding:
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Tax-related matters.
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Coverage termination dates set by the Marketplace.
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Subsidies applied incorrectly.
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Decisions involving repayment of advance premium tax credits after taxes are filed.
For coverage disputes—such as what benefits are included—your client must contact their insurance carrier directly. The Marketplace only ensures the 10 essential health benefits are met; it does not decide how plans administer coverage.
If more than 90 days have passed since your client received their eligibility notice, the decision cannot be appealed unless the Marketplace agrees to grant an extension.
Requesting an Extension
If your client missed the 90-day window, you can ask the Marketplace to extend the deadline. Approval isn’t guaranteed—the Marketplace will review the request and decide whether circumstances justify the delay.
How the Appeal Process Works
The appeals procedures described here apply to the federal Marketplace (HealthCare.gov). If you work in a state-based exchange, check that state’s rules—many states have shorter deadlines, sometimes as brief as 30 days.
1. Become Your Client’s Authorized Representative
To act on your client’s behalf, you must be listed as their authorized representative specifically for the appeals process—even if you are already connected to their Marketplace application.
This authorization can be completed when the appeal is submitted, either electronically or in writing.
To file online:
Visit the Marketplace Appeals Center, select your state, and follow the system prompts.
2. Submitting an Appeal by Mail or Fax
Clients in FFM states may also send an appeal letter to:
Marketplace Appeals Center
PO Box 31
Pittston, PA 18640
Fax: 1-877-369-0129
State-based exchange clients must follow their state’s instructions.
An appeal letter must include:
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Client’s full name, address, and phone number
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Appeal number (if one exists)
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A written statement authorizing you to represent them
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Your contact information
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Permission for the Appeals Center to discuss the case with you
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Client’s signature and date
Clients may revoke your authorization at any time by calling 1-855-231-1751.
If the situation calls for an expedited review due to medical need, make this clear in the initial submission.
3. Respond Quickly — Timeliness Matters
Fast communication is essential. Encourage your client to respond promptly to Marketplace requests and gather supporting documents as soon as possible.
Keep copies of:
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All letters
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Forms
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Recorded communications
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Documents submitted for the appeal
You may request additional copies of appeal documents through the Marketplace Appeals Center or by submitting an online request.
Each case receives a unique appeal number—include this on all future correspondence.
4. Expedited Appeals
If waiting for a decision could seriously harm your client’s health—for example, if they need urgent medication or are hospitalized—they may request a faster appeal.
A request for expedited review can be made:
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Online
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Through the appeal form
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Within the appeal letter
Even with an expedited process, the timeline varies depending on the issue and how long it takes to gather supporting documents. The Marketplace prioritizes these cases and will send confirmation of the expedited request by mail.
What Happens After an Appeal Is Submitted
Once the Marketplace receives the appeal, your client will get a letter confirming:
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The appeal was accepted
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Their appeal number
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What happens next
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Whether additional information is needed
The Marketplace may also call you or your client for clarification—quick responses prevent delays.
Clients can track appeal activity on HealthCare.gov or through HealthSherpa by:
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Logging in
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Opening the current application
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Selecting Eligibility & Appeals
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Choosing File a new appeal or Check appeal status
There are five stages in the appeal review process:
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Submitted – The appeal has been received.
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In Review – Marketplace is assessing the appeal and documents.
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Informal Resolution – Marketplace may request more information and issue an initial decision.
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Hearing – If your client disagrees with the informal resolution, they may request a hearing with a Federal Hearing Officer.
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Final Decision – A decision is issued with instructions for next steps.
Temporary Benefits While Appealing
The Marketplace may offer your client temporary coverage while the appeal is pending. If they accept and later lose the appeal, they might have to repay benefits they were not eligible for. Make sure clients understand the risks before agreeing.
The Final Decision
If your client agrees with the informal resolution, that decision will stand. If not, they may move forward with a formal appeal hearing. Hearings are conducted by phone, under oath, and clients receive at least 15 days’ notice.
Final decisions are typically issued within 90 days of the hearing. The decision letter will outline next steps and any outstanding financial obligations or refunds owed.
Your Responsibilities as the Agent
As the authorized representative, you are expected to:
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Respond to Marketplace calls and requests
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Provide documentation promptly
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Attend scheduled calls, meetings, or hearings
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Maintain accurate records
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Communicate results and next steps to your client
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Submit plan selections or updates after the appeal decision
Acting as an authorized representative is a significant responsibility—know the process, stay responsive, and support your client through every stage.
Why Appeals Matter
The appeals process can be critical for clients who:
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Were improperly denied coverage
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Should have qualified for greater financial assistance
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Need access to more affordable insurance options
A successful appeal can meaningfully change what your client pays—or whether they can get coverage at all.
Not affiliated with or endorsed by Medicare or any government agency.
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