Appeals FAQs

Employers | Customers

Employers

Q: Why did my business receive the “Employer Notification” letter?

The Affordable Care Act requires us to notify you when one of your employees purchases health insurance through WA Healthplanfinder and is eligible to receive tax credits. The letter tells you that the person named in the letter will soon receive tax credits.  The insurance they purchased and the tax credits will start on the first day of next month.

If you have not made an offer to insure the person named in the letter, there is nothing more you need to do.

Q: How do I know if my business needs to do anything about the letter?

You only need to contact us if you did offer employer-sponsored insurance to the person named in the letter.

Q: Is the letter about this year or last year?

This notice is for enrollment that will start on the first day of the month after the date on the notice. The letter notifies you of the employee’s current eligibility for tax credits.

Q: My employee may be eligible for employer-sponsored insurance in the future.  What should I do now?

There’s nothing to do right now.  There is no dispute until they are eligible for employer-sponsored insurance.  If you’re not sure, please contact us for more information.

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 the employee when the time comes.

Q: I don’t think this employee should receive tax credits. How do I resolve this?

Email us at appeals@wahbexchange.org. Be sure to include the application ID number shown at the top of the Employer Notification letter. We can tell you exactly why you received this letter.   Often, the employee just misunderstood a couple of questions on the Washington Healthplanfinder application.  If they answered a question incorrectly, the employee just needs to update their application with the correct answer.

The employee might have answered any of the following question(s) 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?
    • Select all members offered coverage under this plan.
  • 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 probably shouldn’t receive tax credits.

Q: I’ve talked to the employee and they want to correct their Washington Healthplanfinder application. What should I do?

The employee can update their Washington Healthplanfinder account online.  We can email step-by-step instructions to the employee or to you. The employee will need information you have to update their account. Please let your employee know how much the monthly premium is for the cheapest employee-only plan.

Q: My employee says they’ve corrected their Washington Healthplanfinder application. How can I know for sure?

Ask the employee to give you a copy of their “eligibility decision” that shows they’re not eligible for tax credits. A copy is posted on their WA Healthplanfinder account the day after they update their application. You can also email us at appeals@wahbexchange.org. Ask us to verify the employee’s information. Be sure to include the application ID number shown at the top of the Employer Notification letter.

Q: The person named in the letter isn’t eligible for our employer-sponsored insurance because they are part-time, a contractor, a vendor, or in their waiting/probationary period. Do I need to do anything?

Probably not. 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 more you need to do.

Q: We don’t offer health insurance to our employees. Do I need to do something?

If you don’t offer health insurance to your employees, there’s nothing more you need to do.

Q: What is an appeal?

An appeal is a hearing held by telephone with a Presiding Officer (a judge) to resolve a dispute when you believe your employee should not be eligible for tax credits. The Washington Health Benefit Exchange selects the date of the hearing and schedules it with the Presiding Officer. The Exchange takes no position in these appeals because it is a dispute between you and the employee.

Q: Do I have to file an appeal or is there a faster way to resolve this issue?

No. An appeal or hearing isn’t required. This is an informal way to resolve the dispute with your employee.

We encourage you to explain to your employees that they may not be eligible for tax credits since you offer employer-sponsored insurance that meets the requirements of the Affordable Care Act. We are happy to work with you and help your employee update their WA Healthplanfinder application.  The informal process still protects both the employer and the employee from potential adverse tax consequences.

Q: If we file an appeal with the Washington Health Benefit Exchange, does that guarantee that the IRS will not penalize us?

No. The Affordable Care Act gives the IRS complete authority to penalize both the employer and the employee if an employee receives tax credits for which they are not eligible. An appeal does not guarantee that the IRS will not penalize your business. In other words, the IRS does not consider the outcome of an appeal filed through the Washington Health Benefit Exchange.

Q: Why is this employee eligible for tax credits?

Many things determine if someone is eligible for tax credits. But it is most often because the employee didn’t answer a question on their application accurately.  Contact us for more information about how to help the employee correct their application.

Q: The person named in the letter has never worked for this company or is no longer an employee. What should I do?

If the person named in the letter never worked for you or is no longer an employee, then there is nothing more you need to do.

Q: I’m a small employer and don’t have to offer insurance to my employees but I do.  Do I need to do anything about this notification?

If you offered employer-sponsored insurance to this employee (even if the law doesn’t require you to), the person named in the letter may still be eligible for tax credits. Contact your tax preparer or legal counsel for more information.

Q: The letter doesn’t list the employee’s name, just an application ID number. How can I find out which employee the letter is about?

If the employee’s name is missing from the letter, please email the application ID number to us at appeals@wahbexchange.org. We will help you identify the correct employee.

Q: I have more than one employee with this name. How can I find out which employee the letter is about?

If you have multiple employees with the same name, please email the application ID number to us at appeals@wahbexchange.org.  We will help you identify the correct employee.

Q: Do I have to offer insurance to my employees?

We cannot answer this question for you.  Consult your legal counsel or tax professional or contact the IRS to learn more about the employer responsibility mandate.

Q: If my employee corrects their Washington Healthplanfinder application, they will probably lose their tax credits and may not be able to afford the insurance they purchased through Washington Healthplanfinder. As the employer, can we let this employee enroll in the employer-sponsored insurance even if it’s outside of our open enrollment period?

Employer-sponsored insurance is often cheaper than the insurance your employee purchased through Washington Healthplanfinder.  You may be able to open a special enrollment period to the employee.  Please ask your tax preparer or legal counsel for more information.

Customers or Individual Appeals

Q: I just received a decision about affordable health insurance coverage for me or my family. I don’t agree with the decision. What can I do?

You may appeal a recent eligibility determination as long as it’s been less than 90 days from the date on your eligibility notice. An appeal is a hearing with a Presiding Officer or judge.

Learn more about contacting the Appeals Program or submitting an appeal request.

Q: Who do I contact if I want to resolve my issue without going to a hearing?

There is always an opportunity to resolve your case at any stage in the hearing process. If you’re interested in doing that, email or call the Appeals Program. We are happy to try to resolve your case quickly.  You can withdraw your request for a hearing at any time.

Q: What can I appeal?

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

  • Failure of the Exchange to provide timely notice of your eligibility decision
  • The amount of your premium tax credit
  • The amount of your cost sharing reduction
  • The denial of a request for a special enrollment period

Q: What kinds of things can’t I appeal?

Our Presiding Officers don’t have authority to rule on matters like:

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

Q: When should I request a hearing?

Contact us first to see if we can resolve your dispute immediately.  If we can’t, send in an appeal request form. Remember, you have 90 days from the date on the eligibility notice you disagree with to request a hearing.

Q: What happens after I file an appeal?

There are several steps in this appeal process. Most appeal cases follow the steps below.

  1. You request an appeal by contacting the WA Health Benefit Exchange Appeals Program.
  2. We open a case and assign an Appeals Specialist to the case.
  3. The Appeals Specialist contacts you to find out more about your dispute.
  4. The Appeals Specialist schedules the pre-hearing conference and hearing with you and the Presiding Officer.
  5. The Appeals Specialist notifies you of the date and time and gives you a phone number to call into the hearing.
  6. If you have evidence for the Presiding Officer, email it to the Appeals Specialist assigned to your case.
  7. At the hearing, you (or your authorized representative) represent yourself, the Appeals Specialist represents the WA Health Benefit Exchange, and the Presiding Officer makes a final decision.
  8. If the Presiding Officer can’t resolve the issue right away, they will schedule a hearing.
  9. The Presiding Officer drafts a written decision.  The Appeals Specialist sends it to you for your records.
  10. If you disagree with the Presiding Officer’s decision, in some situations you may appeal the decision to the U.S. Department of Health and Human Services.

Q: Do I have to hire an attorney to represent me in this matter?

No.  Most people represent themselves, but you may hire a person to act on your behalf if you prefer.  The Exchange does not pay for an attorney if you choose to hire one.

For more information about free or low-cost legal services in your area, call the Coordinated Legal Education, Advice, and Referral System (CLEAR) at 1 -888-201-1014. You can find other resources at the Northwest Justice Project, Columbia Legal Services, the Northwest Women’s Law Center, some law schools, mental health regional support networks, and other non-profit legal organizations.

Q: What information should I send with my request for an appeal?

Send any information you think the Presiding Officer needs to make a decision.

Q: I have a medical condition, and for health reasons, I need a hearing scheduled very quickly. What should I do?

When you request a hearing, you must also include documentation that clearly shows why, without an immediate hearing, your life or health, or your ability to attain, maintain, or regain maximum function, will be in danger. Medical records, doctor statements, physical therapy notes, and other documents can show your need for an immediate hearing. The Presiding Officer will decide whether to grant your request for an expedited hearing, based on the documents you submit. If the Presiding Officer grants your request for an expedited appeal, the Presiding Officer will render a decision within 14 calendar days.

Q: What happens to my eligibility while I wait for my appeal hearing?

Your premium tax credit or cost-sharing reduction amount remains the same until the Presiding Officer makes a decision on your appeal.

Q: May I have more time to file my appeal?

No. The federal rules give you 90 days to request an appeal.

Q: How will I know when the hearing will be scheduled?

Within 2 weeks of requesting a hearing, the Appeals Specialist assigned to your case will contact you. You can discuss hearing dates and times during that phone call.

The Appeals Specialist will schedule the hearing and send you a hearing notice.  The notice includes several important deadlines as well as the date and time of your pre-hearing conference and appeal hearing. It’s very important that you keep track of the deadlines and the meeting dates and times.

Q: May I request a different hearing date or change the schedule?

Usually.  Your request must be in writing and include the reasons why you’re requesting a new hearing date. Send your request to your Appeals Specialist.  The Presiding Officer will make the decision whether to change your hearing date or not.

Q: I requested a hearing, but now I’ve changed my mind. What should I do?

You may withdraw your request at any time. Contact the Appeals Specialist.  They will provide you with a form to complete, indicating you want to withdraw and cancel your request for a hearing.

Q: What is the pre-hearing conference?

The pre-hearing conference is an opportunity for you, the Appeals Specialists, and the Presiding Officer to prepare for the hearing. At the pre-hearing conference, you or your representative, if you have one, the Appeals Specialist, and the Presiding Officer will consider several matters, including:

  • The issues to be addressed at the subsequent hearing
  • The witnesses (if any) who will testify
  • The documents to be submitted at the hearing
  • If an informal resolution is possible at the pre-hearing conference
  • Any other matters regarding the efficient conduct of the hearing

Like the hearing, the pre-hearing conference will be a telephone conference call.

The judge may issue a ruling at the pre-hearing conference.

Q: What information will the Presiding Officer use to make his/her decision?

The Presiding Officer will use the information you provided when you applied through Washington Healthplanfinder. You may submit additional materials as well. The Appeals Specialist may also submit evidence. You will have time to review all those materials before the pre-hearing conference.

Q: How do I get my evidence to the Presiding Officer?

To present information or evidence at the hearing, you must email, fax, or mail it to your Appeals Specialist several days before the hearing. The Presiding Officer will need to review the evidence before the hearing.

Q: What if I need an interpreter or special accommodation?

If you or a witness need a language interpreter or translator, the Exchange will provide one to you at no cost. Contact the Appeals Program immediately if you need an interpreter or translator. You may not use a friend or relative as your language interpreter or translator at your hearing. If you need other accommodations, contact the Appeals Program to discuss the accommodation.

Q: I moved recently. Whom should I tell?

Update your address in WA Healthplanfinder and contact the Appeals Program immediately with your new address. We send important documents to the mailing address you gave us, so be sure we have the right one

Q: How long will it take to get a final decision?

The Affordable Care Act requires the Exchange to make a decision less than 90 days after the date we receive your request for a hearing. Complex cases can take up to 90 days. We will schedule your pre-hearing conference 3-8 weeks after we receive your request. In most cases, the judge can resolve the matter during this pre-hearing conference.

Q: Will my appeal affect my ability or the ability of my household members to get low-cost insurance coverage, Washington Apple Health, or tax credits?

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 Presiding Officer makes a decision, we will tell you how the decision affects you and the people in your household.

Q: What if I don’t agree with the Exchange appeal decision?

In some cases, but not all, you may appeal the Presiding Officer’s decision to the U.S. Department of Health and Human Services. The Presiding Officer’s order will include information about how to appeal to the U.S. Department of Health and Human Services if that is an option.

Q: Washington Healthplanfinder denied me enrollment into Washington Apple Health (Medicaid), but I think I’m eligible. What should I do?

You may appeal this decision to the Health Care Authority, which oversees Washington Apple Health. If you also want to appeal an additional Washington Healthplanfinder decision that is not related to Washington Apple Health, you may file one appeal for both issues with the Exchange. You decide which appeal request takes priority. Be sure to let us know if you prefer to get a decision on your Washington Apple Health eligibility first. Remember, you only have 90 days to request an appeal, so don’t delay.

Last updated 9/20/17