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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 is found eligible to receive tax credits that help offset the cost of their health insurance premiums. The letter is telling you that the person named will be eligible to receive tax credits on the first day of next month.

If you have not offered employer-sponsored insurance to the person named in the letter, there’s nothing more you need to do.

Please note that this notification has nothing to do with whether your company must provide insurance to your employees or not. The only thing that matters is whether your employee will be eligible next month for employer-sponsored insurance and therefore shouldn’t receive tax credits.

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

If you did not offer health insurance to the person named in the letter (regardless of the reason), then there’s nothing more you need to do. Simply file the letter with this year’s tax documents.

If you did offer health insurance to the person named in the letter, then we encourage you to email or call us so we can tell you exactly why we sent you this notice. We are happy to discuss your options.

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

The notice is for tax credits 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: If my employee may be eligible to sign up for employer-sponsored insurance in the future, what should I do now?

If the employee’s status changes in the future and they become eligible for your employer-sponsored insurance, they must update their Washington Healthplanfinder account. Most employees don’t know they need to update their account, so remind the employee when the time comes. After the employee updates their account, they may or may not be eligible for tax credits. If they are eligible for tax credits, you’ll get another notice.

Q: I don’t think the 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 usually determine the exact reason you received the letter.  The employee may have misunderstood some of the questions on the Washington Healthplanfinder application and answered them incorrectly.

The question(s) that may have been answered incorrectly include:

  • 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 be eligible for 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, or they can contact us and we can help them correct their application over the phone. Once the employee corrects their application, we’ll send the employee a new eligibility determination. If the employee is still eligible for tax credits, you’ll get another letter.

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

You can ask the employee to give you a copy of their updated eligibility decision that shows they’re not eligible for tax credits. You can also email us at appeals@wabhexchange.org and 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: My employee 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?

You’re receiving this notification because the person named in the letter identified you as their employer. But, the Washington Health Benefit Exchange doesn’t know the employment status of this person. If you didn’t offer health insurance to the person named in the letter, there’s nothing more you need to do. We recommend that keep the letter with this year’s tax documents.

Q: We don’t offer health insurance to our employees. Why did I get the Employer Notification letter and do I need to do anything?

The Washington Health Benefit Exchange doesn’t know if you offered insurance to the person named in the letter, so the Affordable Care Act requires us to notify every employer anytime an employee is eligible for tax credits.

If you don’t offer health insurance to your employees because you don’t have to, there’s nothing more you need to do. We recommend that keep the letter with this year’s tax documents.

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 both the date of the hearing and the Presiding Officer. The Exchange takes no position in these appeals because it is a dispute between you and the employee. We encourage you to contact us and contact your employee before requesting a hearing. Most employees are willing to update their application and resolve the issue when the employer gives them that opportunity. This informal process is faster and less stressful than the appeals process, but every employer has the right to request a hearing.

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

You have a right to appeal the decision that your employee is eligible for tax credits, but an appeal is not a requirement. Because most employees want to correct their Washington Healthplanfinder applications, they are usually willing to resolve everything without having to attend a hearing. We encourage you to help your employees understand that they may not be eligible for tax credits since you offer employer-sponsored insurance that meet the requirements of the Affordable Care Act.

Q: If we file an appeal with the Washington Health Benefit Exchange, does that guarantee that the IRS won’t 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. We want every employee’s Washington Healthplanfinder application to accurately reflect whether they were or were not offered employer-sponsored insurance.  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?

There are many elements that go into making a determination that someone is eligible for tax credits. The most common reason is that the employee attested that they were not offered employer-sponsored insurance or they reported that their employer’s insurance wasn’t affordable. If this is isn’t accurate, we can 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), they may not be eligible for tax credits. Email us at appeals@wahbexchange.org and we’ll let you know.

If you don’t offer employer-sponsored insurance to your employees, then there’s nothing more you need to do. Your employees are eligible for tax credits.

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?

This notification is not related to whether your company must provide insurance to your employees or not. Unfortunately, we don’t know enough about your business to determine whether your business must offer insurance to your employees or not. The IRS has information about the employer responsibility mandate. Ask your tax preparer or your legal counsel if you have more questions about how to comply with the Affordable Care Act.

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?

You may be able to but you’ll need to get information from your human resources or legal department to be sure. The Affordable Care Act considers a loss of tax credits a qualifying life event. You may offer employer-sponsored insurance to your employee through a special enrollment period. In most cases, the insurance you offer your employees is cheaper than insurance they purchase through Washington Healthplanfinder without tax credits.

Customers

Q: I just received a recent 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 made by the Washington Health Benefit Exchange as long as it’s been less than 90 days from the date on your eligibility notice.

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

Q: What kinds of things 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: When should I file an appeal?

You should file an appeal as soon as you can, but you must request an appeal within 90 days of the date on your eligibility notice.

Q: What happens after I file an appeal?

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

  1. When the Exchange Appeals Program receives your appeal, we assign an appeals specialist to you. The specialist is your point of contact when you have questions or need assistance from the Appeals Program.
  2. We send you the hearing schedule. This schedule includes important deadlines and your hearing date and time.
  3. You may send us documents or evidence that support your position and help explain your concerns.
  4. Your appeals specialist will review everything you send us and may call or email you to get more information.
  5. You (or your authorized representative, if you have one) participate in a pre-hearing conference with your appeals specialist and the Presiding Officer. The pre-hearing conference is conducted over the phone as a conference call.
  6. After the pre-hearing conference, you’ll participate in the appeals hearing. This hearing is also conducted over the phone as a conference call.
  7. The Presiding Officer will make a decision and we will send you that decision in writing.
  8. If you disagree with the Presiding Officer’s decision, you may appeal that 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?

You may hire a person, such as a lawyer or an organization to act on your behalf. However, this isn’t required. In appeals like these, many people represent themselves.  The Exchange won’t 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. Other resources may be found 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?

Be sure to send any information you think the Exchange needs to make a fair decision. We recommend you send at least the following information with your request for a hearing:

  • Full name
  • Mailing address and telephone number
  • Email address
  • Social Security number
  • The reason you’re requesting an appeal with as much detail as possible
  • Any documents that will help us understand the reason for your appeal

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

Call the Appeals Program immediately. We will ask you to provide us with information about why you need an expedited hearing. The information you provide should clearly show 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 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 two weeks of requesting a hearing, the Appeals Program will contact you with a hearing schedule. The hearing schedule 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?

Yes, as long as it won’t cause the final decision in the appeal to be made more than 90 days after the Exchange received your appeal. Your request must be in writing and include the reasons why you’re requesting a new hearing schedule. Your request may be emailed to the Appeals Program at appeals@wahbexchange.org or faxed to 360-841-7653.

Q: Who do I contact if I want to settle (resolve) my case 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, call the Appeals Program. We’re happy to try and resolve your case quickly. You can withdraw your request for a hearing at any time.

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 Program, and 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 and the Presiding Officer to prepare for the hearing. At the pre-hearing conference, you or your representative (if you have one), the Exchange appeals specialist, and the Presiding Officer will consider several issues:

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

Like the hearing, the pre-hearing conference will be a telephone conference call, unless you request an in-person hearing.

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’ll be able to submit additional materials as well. The appeals specialist will send you the same information they send the Presiding Officer. You’ll have time to review those materials before the pre-hearing conference.

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

To present additional information or evidence at the hearing, you must email, fax, or mail it to the Appeals Program. The Presiding Officer will review the evidence you submit, discuss it with you at the pre-hearing conference, and decide what evidence may be used in 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, call the Appeals Program to discuss the accommodation.

Q: I moved recently. Who should I tell?

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 in less than 90 days after receiving your request for a hearing. Complex cases may take up to 90 days. Your first hearing with the presiding officer will probably be scheduled about 4 weeks after we receive your request for a hearing. Almost every case gets resolved at this first hearing, which means that most cases are closed in about 4-5 weeks.

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’s likely that the appeal decision will affect your eligibility and possibly the eligibility of one or more of the people in your house. As soon as the Presiding Officer makes a decision, we will tell you how the decision affects you and the people living with you.

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

If you don’t agree with the decision of the Presiding Officer, you may appeal that decision to the U.S. Department of Health and Human Services.

Q: Washington Healthplanfinder denied me, but I think I’m eligible for Washington Apple Health. 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. It’s your choice 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.

Washington Healthplanfinder says I’m eligible for a premium tax credit. What is an advance payment premium tax credit?

You can use this tax credit to lower the health insurance premium costs of Qualified Health Plans. If you’re eligible, the tax credit provides you the option to either reduce the amount of your monthly premium or receive a lump-sum deduction when you file your annual income tax return.

If you choose to take advantage of this tax credit, you’re required to file federal taxes with the IRS. The tax credit is based on the estimated income you provided at the time you applied for health coverage. The actual tax credit will be based on your total actual income for the year as provided on your tax return. The tax filer on your Washington Healthplanfinder account may be responsible to pay back some or all the tax credit to the IRS when you file your tax return.

You can use your tax credit in one of the following ways:

  • Monthly: You can use some or all of your tax credit in advance to lower the cost of your monthly premium.
    1. Pros: Your health plan costs will be less each month. The IRS sends your tax credit directly to your health plan carrier.
    2. Cons: You may owe money at tax filing time if your current household income increases or your household changes.
  • Annually: You can claim your tax credit on your annual tax return, which will reduce what you owe or increase your refund.
    1. Pros: You have no risk of having to repay the IRS at tax filing time.
    2. Cons: Your health plan costs will be more each month.

Last updated 7/25/16