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Marketplace Eligibility Appeal Request Form - Employer (11/2018)
Instructions to help you complete
the Employer Appeal Request
11/2018
Form Approved
Appeal Request Form – Employer
Use this form to
request an appeal
If you received a Marketplace notice stating that you may be subject to the Employer
Shared Responsibility Payment, you can request an appeal by submitting this form or
mailing in a letter that includes the information requested on this form.
Use this form if you’re appealing a notice you received from:
• The federally-facilitated Health Insurance Marketplace
• A state-based Marketplace operating in:
California District of Columbia New York
Colorado Maryland Rhode Island
Connecticut Massachusetts Vermont
This appeal may determine if an employee was eligible for help with the costs of coverage
through the Marketplace at the same time that you may have offered them affordable
health coverage that met the minimum value standard. This appeal will NOT determine
if your organization has to pay the Employer Shared Responsibility Payment. Only the
Internal Revenue Service (IRS), not the Health Insurance Marketplace or the Marketplace
Appeals Center, can determine which employers are subject to the Employer Shared
Responsibility Payment as stated under section 4980H of the Internal Revenue Code.
IMPORTANT: Effective 2016, the Employer Shared Responsibility Payment applies to
employers with 50 or more full-time employees.
• If you want to appeal a Small Business Health Options Program (SHOP) eligibility
decision, visit
HealthCare.gov/small-businesses/provide-shop-coverage/appeal-a-shop-decision for
more information.
Timeframe to
request an appeal
You must submit your appeal request form within 90 days of the date of your
Marketplace notice.
Designating a
secondary contact
You may authorize a secondary contact to help with your appeal. The secondary contact
may act on your behalf, talk with the Marketplace Appeals Center, view your case file, and
receive all correspondence regarding your appeal. To authorize a secondary contact
complete Step 2: Designate a secondary contact.
How to submit this
form
Submit one appeal request per employee listed on the notice you received from the
Marketplace.
Enter your information directly, then print your completed form. Or, print a blank form to
fill in by hand using black or dark blue ink.
Sign the completed form and mail together with any supporting documents to:
Health Insurance Marketplace
Attn: Appeals
465 Industrial Blvd.
London, KY 40750-0061
you may also fax the form and documents to a secure fax line: 1-877-369-0131.
You’ll receive all future correspondence about this appeal from the Marketplace Appeals
Center. The Marketplace Appeals Center is different from the Health Insurance
Marketplace.
Marketplace Eligibility Appeal Request Form - Employer (11/2018)
What happens
next?
1. We’ll send you a notice letting you know that we received your appeal
request. If there’s a problem with the appeal request, we’ll tell you how to
correct the issue. We’ll also send a notice to the employee listed on the
notice you received from the Marketplace.
2. We’ll review your appeal, including all documentation provided by you
and/or the associated employee. If there’s a problem, like if it’s missing information
or we need clarification, we’ll tell you what’s missing and how you can provide
additional information.
3. We’ll send appeal decision notices explaining the outcome of our review to you and the
associated employee.
Additional help
Language assistance services
If you need help with your appeal in a language other than English, you have the right to
get information in your language at no cost. Call the Marketplace Appeals Center at
1-855-231-1751. Hours of operation are Monday through Friday, 7:00 a.m. to 8:30 p.m.
Eastern Time (ET).
Accessibility
To request appeal forms and notices in an alternate format like braille, large print, data CD,
audio CD, or to request a qualified reader, you can call the Marketplace Appeals Center at
1-855-231-1751. TTY users can call 1-855-739-2231. Hours of operation are Monday
through Friday, 7:00 a.m. to 8:30 p.m. Eastern Time (ET). You can also make a request in
writing by fax (1-877-360-0130) or mail (Marketplace Appeals Center, P.O. Box 311, Pittston,
PA 18640). Accommodations are provided at no cost to you.
To submit your appeal request, see “How to submit this form” on page 1 of these
instructions.
Questions
If your state isn’t listed above, or to learn more about your appeal, call the Marketplace
Appeals Center at 1-855-231-1751. TTY users can call 1-855-739-2231. Hours of
operations are Monday through Friday, 7:00 a.m. to 8:30 p.m. Eastern Time (ET).
Privacy and Use of Your Information
The Marketplace protects the privacy and security of information about you that you’ve provided. To view the Privacy Act
Statement, go to HealthCare.gov/individual-privacy-act-statement
. We’re authorized to collect the information on this form and
any supporting documentation, including Social Security numbers, under the Patient Protection and Affordable Care Act (Public Law
No. 111–148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111–152), implementing
regulations in 45 CFR part 155, subpart F, and the Social Security Act. For more information about the privacy and security of your
information, visit HealthCare.gov/privacy
.
Nondiscrimination
The Health Insurance Marketplace doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of
race, color, national origin, disability, sex, or age. If you think you’ve been discriminated against or treated unfairly for any of these
reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil Rights by calling
1-800-368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints
, or writing to the Office for Civil Rights, U.S.
Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201.
Page 1 of 3
Marketplace Eligibility Appeal Request Form - Employer (11/2018)
Employer Appeal Request Form
Use this form to appeal a Marketplace determination that an employee was eligible for advance payments of the premium tax credit and
cost-sharing reductions (if applicable) in part because your business didn’t offer health coverage that met minimum value requirements
that was affordable with respect to this employee.
Enter your information directly, then print and sign your completed form. Or, print a blank form and fill in using black or dark blue ink.
Use capital letters.
STEP 1: Tell us about the employer who’s requesting this appeal.
Enter your information directly, then print and sign your completed form.
1. Organization Name
Federal Employer ID Number (EIN) Organization Phone Number
(
)
Organization’s Primary Mailing Address Suite #
City
State ZIP code
Primary Contact First Name Middle Name
Last Name
Primary Contact phone number
( )
Title of Primary Contact
Organization of Primary Contact (if different than organization listed above)
Primary Contact mailing address Suite #
City State ZIP code
STEP 2: Designate a secondary contact.
This is someone who may act on your organization’s behalf regarding this appeal request.
Secondary Contact First Name Middle Name
Last Name Secondary Contact phone number
( )
Title of Secondary Contact Organization of Secondary Contact (if applicable)
Secondary Contact mailing address Suite #
City State ZIP code
Page 2 of 3
Marketplace Eligibility Appeal Request Form - Employer (11/2018)
STEP 3: Signature
By completing, signing, and dating below, I authorize the Marketplace Appeals Center to perform a review of
whether the employer named on this form offered minimum essential coverage through an employer-sponsored
plan that’s considered affordable with respect to the relevant employee, and meets the minimum value standard.
I understand I may request a copy of my Marketplace appeal record and that certain information about the
relevant employee’s eligibility determination may or may not be made available to me as described in 45 CFR
§155.555(g)(2) and 45 CFR §155.555(h).
By signing this form under penalty of perjury, I declare that I’ve provided true answers to all the questions that I’ve
answered to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false
information.
Signature
1. Print name of primary contact First Name, Middle Name, Last Name
Title
Signature
Date (mm/dd/yyyy)
Page 3A of 3
Marketplace Eligibility Appeal Request Form - Employer (11/2018)
STEP 4: Tell us why you’re appealing the Marketplace
determination of this employee’s eligibility for help
with the costs of Marketplace coverage.
What’s the date on the Marketplace notice?
(mm/dd/yyyy)
What's the employee's Application ID #
(if available on your notice)?
What's the employee's first name?
What's the employee's last name?
What’s the employee’s date of birth
(if available)? (mm/dd/yyyy)
What’s the employee’s address (if available)?
Mailing Address:
City State ZIP code
From which exchange did you receive the Marketplace notice?
The federally-facilitated Health Insurance Marketplace Health Source Rhode Island
Access Health CT Maryland Health Connection
Connect for Health Colorado Massachusetts Health Connector
Covered California New York State of Health
DC Health Link Vermont Health Connect
An individual may qualify for help with the costs of Marketplace coverage if their employer did not offer coverage or if the coverage that’s offered
by an employer doesn’t meet minimum value requirements or isn’t affordable with respect to the employee.
Select your reason for appeal and then use the space below to explain why this employee shouldn’t have been eligible for advance payments of the
premium tax credit and cost-sharing reductions (if applicable). Use extra paper, if necessary. Please send a copy of the Marketplace notice that
identifies this employee when you submit your appeal request. If you’re including documents to support your request, send us copies. Keep all
original documents.
This employee was enrolled in employer-sponsored coverage.
This employee was offered affordable employer-sponsored coverage which met the minimum value standard.
This employee was eligible for affordable employer-sponsored covered that met the minimum value standard after the end of a waiting period.
(Note: You will need to show when the employee was offered employer-sponsored coverage and when the waiting period ended.)
Note: The following reasons for appeal fall outside of the jurisdiction of the Marketplace Appeals Center:
• The employee listed on the Marketplace notice has not worked for your company this year.
• The employee listed on the Marketplace notice is not a full-time employee.
• The employee listed on the Marketplace notice is not your company’s employee.
• Your company does not employ at least 50 employees.
Page 3B of 3
Marketplace Eligibility Appeal Request Form - Employer (11/2018)
STEP 4: (continued)
Explain why this employee shouldn’t have been eligible for advance payments of the premium tax credit
and cost-sharing reductions (if applicable). Please send a copy of the Marketplace notice that identifies
this employee when you submit your appeal request. If you’re including documents to support your
request, send us copies. Keep all original documents.
To view the acceptable documentation please refer to the Employer Document Guide at cms.gov/CCIIO/Programs-and-
Initiatives/Employer-Initiatives/Employer-Initiatives.html
. Please submit a copy of the necessary documentation for each
unique employee appeal.
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Form Approved: Instructions to help you complete the (Centers for Medicare & Medicaid Services)

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Completed 19 July 2020

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