Employer Appeal Request Form

Form

Form

Form

Dispute Details

Select one:

The employer offered the below employee health insurance that meets the affordability, Minimum Essential Coverage, and Minimum Value Standard requirements of the Affordable Care Act.

The employer did not offer the below employee health insurance that meets these standards.

How much does it cost an employee for self-only coverage in the lowest cost plan that meets ACA requirements?

Monthly Cost

Application ID on Notification

Date of Notice

Employee Information

First Name

Last Name

Employer Information

Name of Business

Mailing Address

City

State

ZIP Code

Employer Representative Information

First Name

Last Name

Job Title

Phone Number

Email Verification

IMPORTANT: Section 4980H of the Internal Revenue Code (IRC) outlines employer shared responsibility provisions. Compliance with IRC is determined by the IRS, based on annual tax filings. The fastest way to resolve an issue regarding an employee’s coverage or advance premium tax credit eligibility is to work directly with the employee; an appeal is not required. For more information about how to resolve this issue without a hearing, read the Appeal FAQs for Employers, email the Appeals Program at [email protected], or call 1-855-859-2512.