Marketplace Employer Appeal Request Form - U.s. Centers For Medicare And Medicaid Services

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08/2017
Form Approved
OMB No. 0938-1213
Instructions to help you complete
Appeal Request Form – Employer
the Employer Appeal Request
Use the right
If you received a Marketplace notice stating that you may be subject to the
Employer Shared Responsibility Payment, you can request an appeal by submitting
form to request
this form or mailing in a letter that includes the information requested on this
an appeal
form.
Use this form if you’re appealing a notice you received from:
• The federally-facilitated Health Insurance Marketplace
• A state-based Marketplace operating in:
California
Maryland
Rhode Island
Colorado
Massachusetts
Vermont
District of Columbia
New York
This appeal may determine if an employee was eligible for help with the costs of
coverage through the Marketplace at the same time that you may have offered
them affordable health coverage that met the minimum value standard. This
appeal will NOT determine if your organization has to pay the Employer
Shared Responsibility Payment. Only the Internal Revenue Service (IRS), not the
Health Insurance Marketplace or the Marketplace Appeals Center, can determine
which employers are subject to the Employer Shared Responsibility Payment as
stated under section 4980H of the Internal Revenue Code.
IMPORTANT: For 2015, the Employer Shared Responsibility Payment will generally
apply to employers with 100 or more full-time equivalent (FTE) employees, and may
apply to certain employers with 50 or more FTE employees. Starting in 2016, the
Employer Shared Responsibility Payment will apply to employers with 50 or more
FTE employees.
• If you want to appeal a Small Business Health Options Program (SHOP) eligibility
HealthCare.gov/small-businesses/provide-shop-coverage/
decision, visit
appeal-a-shop-decision/
for more information.
Timeframe to
You must submit your appeal request form within 90 days of the date of your
Marketplace notice.
request an appeal
Designating a
You may authorize a secondary contact to help with your appeal. The secondary
contact may act on your behalf, talk with the Marketplace Appeals Center, view
secondary contact
your case file, and receive all correspondence regarding your appeal. To authorize a
secondary contact complete Section 2: Designate a secondary contact.
How to submit
Submit one appeal request per employee listed on the notice you received from
the Marketplace.
this appeal
Enter your information directly, then print your completed form. Or, print a blank
request form
form to fill in by hand using black or dark blue ink.
Sign the completed form and mail to:
Health Insurance Marketplace
Attn: Appeals
465 Industrial Blvd.
London, KY 40750-0061
You may also fax the form to a secure fax line: 1-877-369-0131.
You’ll receive all future correspondence about this appeal from the Marketplace
Appeals Center. The Marketplace Appeals Center is different from the Health
Insurance Marketplace.

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