Appeals FAQs

An appeal is a legal dispute. When you submit an appeal, you are asking for us to schedule a hearing with a Presiding Officer (judge) so that the judge can decide if the Exchange made an error. 

Once you file an appeal, you become “the appellant”. The Exchange cannot close your case unless you ask us to close it (withdraw your appeal) or until the judge makes a ruling and tells us the case is closed.

Decisions you may appeal include, but are not limited to:

  • Eligibility for Advance Premium Tax Credit or the amount of your advance premium tax credit
  • Eligibility for lower out of pocket costs or the amount of your cost-sharing reductions
  • Eligibility for a special enrollment period
  • Eligibility for benefits available to enrolled American Indian/Alaska Natives
  • Failure of the Exchange to provide timely notice of your eligibility decision

Our judges do not have authority to rule on the following issues:

  • Decisions made by your insurance carrier
  • Billing or payment issues
  • Eligibility for or enrollment in Washington Apple Health (Medicaid)
  • Cancelation or termination of insurance for failing to pay premiums
  • Penalties issued by the Internal Revenue Service (IRS)

There are several steps in this appeal process. Most appeals follow these steps:

  1. You submit your Appeal Request.
  2. A case is opened and assigned to an Appeals Specialist.
  3. The Appeals Specialist contacts you to find out more about your dispute.
  4. The Appeals Specialist schedules a pre-hearing conference with you and the judge.
  5. The Appeals Specialist notifies you of the date and time and gives you a phone number to call into the prehearing conference.
  6. If you have evidence or documents that support your case, send it to the Appeals Specialist and it will be shared with the judge.
  7. At the prehearing conference, you represent yourself, the Appeals Specialist represents the Exchange, and the judge asks questions. You may authorize someone to represent you by providing their information on your appeal request form.
  8. If the judge has enough information, they will decide after the prehearing conference. If the judge can’t resolve the issue right away, they will schedule a hearing.
  9. The judge issues a written decision. The Appeals Specialist sends it to you for your records.
  10. If the judge orders a change to your eligibility, the Appeals Specialist will update or correct your Washington Healthplanfinder account and you will receive updated Eligibility Results.

If you disagree with the judge’s decision, you may appeal to the U.S. Department of Health and Human Services. The judge’s decision will contain Information about how to file this 2nd level appeal.

Please contact Customer Support at 1-855-923-4633 or contact a local navigator or broker. You may request to submit a ticket. 

If you cannot get resolution through Customer Support or the ticket process, you can file a complaint using our online complaint form.

No. Most people represent themselves, but you may authorize or hire someone to represent you. The Exchange will not pay for your attorney if you hire one.

Send any information you think the judge needs. If you believe your eligibility is wrong, it is up to you to explain or show why. 

The Appeals Specialist will review the information you provide and if your documents show that there was a mistake, the Appeals Specialist may be able to correct your eligibility quickly, without having to wait for the judge’s decision. If the reason for your appeal gets resolved informally, you would be able to withdraw your appeal and the process would end.

The judge must issue a decision within 90 days of the date your appeal is received by the Exchange. Most appeals don’t take this long and they are processed in the order they were received.

You can request an expedited hearing by including documentation that shows your life or health, or your ability to attain, maintain, or regain maximum function, will be in danger without an immediate hearing. Medical records, doctor statements, physical therapy notes, and other documents might show your need for an immediate hearing. The judge will decide whether to grant your request for an expedited hearing based on the documents you submit. If the judge grants your request for an expedited appeal, the judge will provide a decision within 14 calendar days.

No. Federal rules give you 90 days from the date on the eligibility results in dispute to request an appeal.

The Appeals Specialist will contact you in writing and send you a hearing notice. This is usually done through email and mail. The notice includes important information, including the date and time of your pre-hearing conference and/or hearing. It’s very important that you keep track of the meeting dates and times; if you don’t appear at your prehearing conference or hearing, your appeal will be dismissed without a ruling.

Yes. If you’d like to request a different day or time, send your request in writing with your reason to your Appeals Specialist. The judge will decide whether to reschedule. The judge usually grants requests unless it would cause your appeal to go beyond the 90-day deadline when the appeal must be resolved.

You may withdraw your appeal at any time. Contact the Appeals Specialist who is working on your appeal case. They will provide you with a form to complete to withdraw your appeal and cancel your hearing. You can also send an email – just make sure to be clear that you are requesting to withdraw your appeal and cancel the hearing.

The pre-hearing conference is an opportunity for you, the Appeals Specialist, and the judge to prepare for the hearing. At the pre-hearing conference, you or your representative (if you have one), the Appeals Specialist, and the judge will examine:

  • The issues to be addressed
  • The witnesses (if any) who will testify
  • The documents that are needed
  • If informal resolution is possible
  • Anything else that would ensure efficient conduct of the hearing

If the judge believes that there is enough information to make a ruling without the need for a full hearing, they can do so. The pre-hearing conference and hearing are telephone conference calls.

The judge will use the information you provided when you applied through Washington Healthplanfinder. You may submit additional materials as well. The Appeals Specialist will submit evidence supporting the eligibility results in dispute. You will have time to review documents and evidence before the pre-hearing conference and hearing (if there is one).

Send your supporting documents to the Appeals Specialist assigned to your case. The Appeals Specialist will forward it to the judge.

If you or your witness need a language interpreter or translator, the Exchange will provide one at no cost. Contact your Appeals Specialist immediately if you need an interpreter or translator. Contact your Appeals Specialist if you need other accommodations.

Update your address in Washington Healthplanfinder and contact your Appeals Specialist with your new address. We send important documents to the mailing address that you provided on your Washington Healthplanfinder account.

Federal rules require the Exchange to resolve your appeal in 90 days or less, from the date we received your appeal. Most appeals are resolved more quickly than that, but complex cases can take up to 90 days. We will schedule your prehearing conference soon after we receive your appeal. In most cases, the Appeals Specialist can resolve the matter earlier or the judge can make a decision after the pre-hearing conference.

It is likely that the appeal decision will affect your eligibility and possibly the eligibility of one or more of the people in your household. As soon as the judge makes a decision, you will get a copy of the decision and updated eligibility results in your Washington Healthplanfinder account.

You may appeal the judge’s decision to the U.S. Department of Health and Human Services (HHS). The judge’s order will include information about how to appeal to HHS.

You may appeal that decision with the Health Care Authority, the state agency that administers the Washington Apple Health program.

FAQs for Employers

The IRS is the authority on all tax matters. The IRS website says, in part, that an Applicable Large Employer (ALE) will owe an employer shared responsibility payment if it does not offer minimum essential coverage that meets minimum value requirements of the Affordable Care Act (ACA) to its full-time employees OR if the coverage offered is not affordable.

  • For information on who is eligible for the premium tax credit, see the IRS’ Premium Tax Credit page.
  • The terms “affordable” and “minimum value” have specific meanings under the Affordable Care Act. For more information on how an employer knows whether the minimum essential coverage that it offers provides minimum value or is affordable, see the IRS Minimum Value and Affordability Requirements information.
  • Also see IRS ESRP Question and Answers and the ESRP regulations (54.4980H-4; 54.4980H-5).

If you are still concerned, we recommend that you contact your benefits administrator, tax preparer, or legal counsel. The Washington Health Benefit Exchange cannot give you legal or tax advice. There is detailed information on the IRS website.

The Affordable Care Act requires the Exchange to notify an employer when an employee purchases health insurance through Washington Healthplanfinder and is eligible to receive tax credits. The letter tells you that the employee was determined eligible for tax credits because they reported that you didn’t offer health insurance or that it was not affordable. 

If you have not offered health insurance to the employee named in the letter, there is nothing more you need to do. It doesn’t matter why you didn’t offer the coverage. The person may no longer be employed with you, or the person may be a contract employee or a part-time employee. If you did not offer coverage for any reason, you do not have a dispute about that person’s eligibility for tax credit.

You are welcome to contact your benefits administrator, tax preparer, or legal counsel; the Exchange cannot help you decide if you need to take action. An appeal is never required but is a way to resolve a dispute between you and our employee.

The letter notifies you of the employee’s current or upcoming eligibility for tax credits.

When the employee becomes eligible for your insurance, the employee must update their Washington Healthplanfinder account. Most employees don’t know they need to update their account, so please remind your employee when the time comes. Remind your employee that because you offered affordable health insurance, they are not required to enroll, but they must update Washington Healthplanfinder to show that it was offered. They will lose tax credit eligibility but may remain enrolled in their Washington Healthplanfinder coverage. Provide Washington Healthplanfinder’s Customer Support phone number if they need assistance making the update: 1-855-923-4633.

Email us at [email protected]. Be sure to include the application ID number shown at the top of the Letter to Employer. We can tell you why you received this letter. Often, the employee misunderstood questions on the Washington Healthplanfinder application. If they answered a question incorrectly, the employee needs to correct their application. 

The employee might have answered one of these questions incorrectly:

  • Did your employer give you a chance to sign up for health insurance that meets the minimum value standards of the Affordable Care Act?
  • How much does your employer’s insurance cost each month to only cover you?

If the employee answered “No” to the first question or if the employee answered the second question by providing an incorrect premium amount, then the employee should correct their account to get accurate eligibility results.

The employee can update their Washington Healthplanfinder account themselves. We can email step-by-step instructions to the employee or to you. Your employee will need information from you to update their account. Please let your employee know how much it costs per month for the employee to enroll in the lowest cost plan that meets ACA requirements for minimum essential coverage and minimum value. It is important that your employee know the self-only cost and not the cost to enroll a spouse, too, or an entire family.

Ask the employee to show you a copy of their eligibility results letter that says they’re not eligible for tax credits. A copy is posted on their Washington Healthplanfinder Message Center the day after they update their application. You can also email us at [email protected] and ask us to verify the employee’s information. Be sure to include the application ID number shown at the top of the Letter to Employer.

The person in the letter identified you as their employer. If you didn’t offer health insurance to the person named in the letter, there’s nothing further you need to do. You are welcome to consult with your benefits administrator, tax preparer, or legal counsel, but you don’t need to tell us the reason for not offering health insurance. 

If your employee is in a waiting period or moves from part-time to full-time employment, when you offer health insurance, you will want to remind them to update Washington Healthplanfinder to report the offer. You can provide Customer Support’s phone number if they need assistance: 1-855-923-4633.

If you didn’t offer health insurance to this employee, then your employee’s Washington Healthplanfinder application contains accurate information and there’s no dispute. You are welcome to contact your benefits administrator, tax preparer, or legal counsel for information or advice.

An appeal is a legal process that may help resolve this dispute between an employer and an employee. A judge will decide whether health insurance was offered by the employer and whether the employee is eligible for tax credit through Washington Healthplanfinder. Hearings are conducted by telephone conference call with a judge to resolve a dispute when you believe your employee should not be eligible for tax credits. The Exchange does not take a position in these appeals because it is a dispute between the employer and the employee. The judge will issue a decision about the employee’s eligibility for Advance Premium Tax Credit and may order the Exchange to update the employee’s eligibility.

An appeal isn’t required. We encourage you to communicate with your employee to see if you can resolve the matter. Ask if they recently experienced a qualifying life event that would allow them to enroll in your coverage now, such as loss of previous coverage. Remind your employee that you offer coverage and how much it costs. Explain to your employee that they are not likely eligible for tax credits through Washington Healthplanfinder because you offered health insurance that meets the requirements of the Affordable Care Act. Your employee should understand that if they receive tax credits they’re not entitled to, they may have to repay the IRS.

No. The IRS is the sole authority on all tax matters. The IRS determines which employers are subject to the Employer Shared Responsibility payment and which individuals are required to repay tax credits that were received in error. An appeal with the Exchange does not guarantee that the IRS will not penalize a business. The IRS will not consider the outcome of an appeal with the Washington Health Benefit Exchange. 

The IRS will send Letter 226J to an employer if it appears liable for Employer Shared Responsibility payment. The employer has an opportunity to respond before any penalty is assessed.

There are several reasons someone can be determined eligible for tax credits. It might be because your employee simply didn’t answer a question on their Washington Healthplanfinder application. You may email us at [email protected] for more information and for instructions to share with your employee to correct their application.

If you didn’t offer health insurance to the person named in the letter, there’s not likely anything you need to do. You are welcome to consult with your benefits administrator, tax preparer, or legal counsel but you don’t need to tell us the reason for not offering health insurance.

If you offered health insurance to this employee (even if the law doesn’t require you to), your employee’s Washington Healthplanfinder account should say that. Tax credit eligibility depends on many factors so your employee may or may not be eligible for tax credit, but the application must contain accurate information. Communicate with your employee, and contact your benefits administrator, tax preparer, or legal counsel for more information.

If you have more than one employee with the same name, please email the name and application ID number (on the top right-hand side of the letter) to us at [email protected]. We will help you identify the correct employee.

We cannot answer this question for you. Contact your benefits administrator, tax professional, or legal counsel or contact the IRS to learn more about the Employer Shared Responsibility provisions of the ACA.

Ask your benefits administrator. Some employers and some insurance carriers are more flexible than others. Employer-sponsored insurance is often less expensive than the insurance your employee purchased through Washington Healthplanfinder. We encourage you to review your options for opening a special enrollment period for your employee.

FAQs for employees in employer appeals (employer received "Letter to Employer")

If your employer received a “Letter to Employer” saying that you were determined eligible for Advance Premium Tax Credit and they have a right to appeal, you’ll see the letter in your Washington Healthplanfinder Message Center. The reason they received that letter is because your application says they either didn’t offer health insurance to you or that they offered unaffordable health insurance. 

If you misunderstood a question on your Healthplanfinder application and agree that your employer offered affordable health insurance, you’re welcome to correct your account. You can do it yourself, call Customer Support for assistance, or contact the Appeals Program.

You are not required to enroll in your employer’s coverage, but if it meets ACA requirements for Minimum Essential Coverage and Minimum Value, your account needs to show that it was offered. You must also provide the cost for you to purchase self-only coverage in the least expensive plan they offer that meets ACA requirements. 

Once your account contains accurate information, you may not be eligible for Advance Premium Tax Credit but you could remain enrolled in your Washington Healthplanfinder qualified health plan. You’d need to pay full price and you’d lose cost-sharing reductions, which means your deductible, co-pay, and out of pocket maximum will increase. If you receive tax credit you’re not entitled to, you may need to repay the IRS.

Affordability of an employer’s plan is measured by the cost for the employee to purchase self-only coverage in the lowest cost plan that meets ACA requirements. If it costs less than 9.83% (for plans beginning in 2021) of your total household income to purchase self-only coverage – not including anyone else in your household – then the coverage is considered affordable and you are not eligible for tax credit. You may purchase a Washington Healthplanfinder plan at full price, without cost-sharing reductions. If you receive tax credit you’re not entitled to, you may need to repay the IRS.

You are welcome to communicate with your employer. If you correct your Washington Healthplanfinder application so that your employer doesn’t have a dispute anymore, please contact your Appeals Specialist or the Appeals department and let them know that you updated. Your employer  may withdraw their appeal. If you received tax credit in error, you may need to repay the IRS but that is between you and the IRS and won’t involve your employer.