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Small Business Employee Benefits and HR Blog

FAQs - Health Insurance Marketplace Verification and Appeals

June 6, 2014
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This article answers frequently asked questions about the Health Insurance Marketplace's verification and appeals processes.FAQs Marketplace Verification

For background on the Marketplaces, see these general FAQs on the Health Insurance Marketplaces.

I expect my income next year will be much lower than it is currently. Do I have to provide documentation to prove my income will be less?

You may be asked for additional information about your projected income. The Marketplace will compare your estimated 2014 income to other available data on your most recent income (for example, with tax return data.) If you estimate next year’s income will be substantially less than you earned in previous years the Marketplace will ask you to provide documentation to support your estimate. This may include a letter from your employer, a pay stub from your new job or other documents. In some cases, just explaining your changed circumstances may be enough.

How does the Marketplace verify income information?

The Marketplace will check the information you provide against a number of databases (including IRS data, Social Security data, wage databases, and others). If the information you provide is very different from what’s in these databases, you may be asked to provide additional documentation. In addition, at the end of the Application for Health Coverage and Help Paying Costs, you will have to sign that you have provided true answers to all questions to the best of your ability. Knowingly providing untrue information is against the law and could even result in civil money fines.

What documentation is required to request a hardship exemption from the requirement that I have health insurance or pay a penalty?

The required documentation will depend on the type of hardship you experienced. For example, if your hardship involves being unable to afford other medical bills during the past two years, the Marketplace will ask to see copies of those bills. If your hardship involves the death of a family member, the Marketplace will ask to see a copy of the death certificate or newspaper death notice. When you request an exemption from the Marketplace, the application will describe the type of documentation you should provide.

The Marketplace said I must submit additional information to document my eligibility within 90 days, but I missed the deadline. Can I request an extension?

If the Marketplace hasn’t received the requested information within 90 days and you didn’t already ask for an extension, the Marketplace will make a determination based on the information it has.

How do I appeal a Marketplace decision?

You can request an appeal of any Marketplace decision, including decisions about:

  • Whether you’re eligible to buy a Marketplace plan

  • Whether you can enroll in a Marketplace plan outside the regular open enrollment period

  • Whether you’re eligible for lower costs based on your income

  • The amount of savings you’re eligible for

  • Whether you’re eligible for Medicaid or the Children’s Health Insurance Program (CHIP)

  • Whether you are eligible for an exemption from the individual responsibility requirement

To make your appeal, start by reviewing the Marketplace’s decision. You will have received the decision (called a determination or eligibility notice). The notice will explain the reasons for the decision and the process you should follow if you want to appeal. You can make your appeal online or in writing or over the phone by calling the Marketplace call center. 

For more information about appealing a Marketplace decision, see HealthCare.gov.

I think my job-based plan is unaffordable and am not enrolled in it, but my employer has not provided this information. Can I still apply for Marketplace coverage and subsidies without the form?

If your employer has not filled out the form that asks about affordability of your job-based health plan, and you cannot obtain this information from your employer, you should report to the Marketplace what you know about your eligibility for employer sponsored coverage, the cost of that coverage, and whether it meets minimum value.

The Marketplace may try to follow up with your employer and collect or verify this information. The Marketplace will determine your eligibility for subsidies based on the information you provided or based on any information the Marketplace was able to obtain on its own through other follow up with your employer.

Source: HealthCare.gov

Questions about Marketplace Verification and Appeals? Leave a comment and we'll help answer.

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