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Rule sets new insurance marketplace appeals processes

Newly finalized rules from the U.S. Department of Health & Human Services specify appeal processes for the new health insurance marketplaces that differ for individuals and businesses.

When an employee has been determined eligible for advance payments of the premium tax credit or cost-sharing reductions, the rules say the marketplace will notify the employer of the following: the employee’s identity; that the employee has been determined eligible for advance payments of the premium tax credit; that if the employer has 50 or more full-time employees, the employer may be liable for a payment under the employer mandate which will become effective in 2015; and that the employer has the right to appeal the determination.
In the individual market, states that operate their own marketplaces may implement their own appeals processes. If they choose not to, they will default to the federal appeals process, which will also be in place for the federally facilitated marketplaces.
Additionally, individual appellants who are unsatisfied with the results of their appeals to the state may escalate to the federal process. Employers in states that have their own appeals processes do not have that federal appeals escalation privilege.
The federal appeals process for the individual marketplaces includes a preliminary case review, called informal resolution. If the appellant is not satisfied with that outcome, then there will be a formal hearing on the matter.
In the small-business marketplaces, the rules say any state that operates a marketplace must provide the appeals process. They also say a state may choose to operate its own small-business marketplace even if its individual marketplace is federally facilitated.

Heather Stauffer

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