Get Marketplace Appeal Request Form 2019-2024

Gov/marketplace-appeals to Get an appeal request form for other states. Learn more about Marketplace appeals. Page 1 of 4 Appeal Request Form Individual Please print in capital letters using black or dark blue ink only. The authorization is valid until the earlier of The resolution of the appeal or My written notification that I want any or all of my authorized representatives removed from this appeal. I m signing this form under penalty of perjury which means I ve provided true answers to all the questions and I ve answered to the best of my knowledge. Gov/marketplace-appeals/shop-decisions/. Timeframe to request an appeal If you applied in one of the states listed above you must submit your appeal request within 90 days of the date on the Marketplace eligibility determination notice that you re appealing. How to submit this form Complete and sign this form and mail it with copies of any supporting documents to the address shown below. Health Insurance Marketplace Dept. of Health and Human Services 465 Industrial Blvd. London KY 40750-0061 You may also fax the form to a secure fax line 1-877-369-0129. You ll receive all future correspondence about this appeal from the Marketplace Appeals Center. The Marketplace Appeals Center is different from the Marketplace which provided your eligibility determination. What happens next 1. If you don t attend your hearing your appeal will be dismissed. 5. After your hearing you ll get a final appeal decision. Additional help Language assistance services If you need language assistance in a language other than English you have the right to get help and information in your language at no cost. Call the Marketplace Call Center at 1-800-318-2596. Accessibility To request an auxiliary aid or service you can Call 1-844-ALT-FORM 1-844-258-3676. 07/2015 Form Approved OMB No. 0938-1213 Instructions to help you complete the Marketplace Eligibility Appeal Request Form Use the right form to request an appeal Complete and mail the correct request form for your appeal. Use this form in the following states Alaska Arizona Delaware Florida Georgia Illinois Indiana Iowa Kansas Maine Michigan Mississippi Missouri Nebraska Nevada New Hampshire New Mexico North Carolina Ohio Oklahoma Pennsylvania South Dakota Texas Utah Virginia Wisconsin Visit HealthCare. TTY users should call 1-844-716-3676. Send a fax to 1-844-530-3676. Send an email to AltFormatRequest cms. hhs. gov Use this address only to send a letter requesting an auxiliary aid or service Centers for Medicare and Medicaid Services Office of Equal Employment Opportunity Civil Rights OEOCR 7500 Security Boulevard Room N2-22-16 Baltimore MD 21244-1850 Attn CMS Alternate Format Team Choose an authorized representative You have the right to choose an authorized representative to help you with your appeal. This is a trusted person who has your permission to talk with us about your appeal see your information and act for you on matters related to your appeal including getting information about you and signing your To appoint an authorized representative complete and mail the form Appoint an authorized representative for my appeal available at completed an authorized representative form for your Marketplace application you need to complete an additional form for your appeal. Questions If your state isn t listed above or to learn more about your appeal call 1-855-739-2231.