Health Insurance Marketplaces are now sending letters to notify certain employers that one or more of their employees has been determined eligible for advance premium tax credits and cost-sharing reductions and has enrolled in a Marketplace plan. Because these events may trigger penalties under the Affordable Care Act’s “pay or play” provisions for applicable large employers (generally those with 50 or more full-time employees, including full-time equivalents), such employers may seek to appeal an employee’s eligibility determination.
Employer Appeals Process
Employers have 90 days from the date stated on the Marketplace notice to file an appeal. In the appeal, the employer may assert that it provides its employee access to affordable, minimum value employer-sponsored coverage or that its employee is enrolled in employer coverage, and therefore that the employee is ineligible for advance payments of the premium tax credit or cost-sharing reductions.
This appeal can generally be filed two ways, either by:
- Filling out the Employer Appeal Request Form; or
- Submitting a letter with the following information:
• Business name
• Employer ID Number (EIN)
• Employer’s primary contact name, phone number, and address
• The reason for the appeal
• Information from the Marketplace notice received, including date and employee information
Employers should mail or fax the appeal request form or letter—with a copy of the Marketplace notice—to the address or fax number provided by Healthcare.gov. After the appeal is filed, the employer will get a letter saying the appeal was received; the letter will provide a description of the appeals process and instructions for submitting additional materials if needed.
Note: An appeal will not determine if the employer is subject to a “pay or play” penalty, as only the IRS, not the Marketplace or the Marketplace Appeals Center, can make such determinations.
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