How to appeal your Virginia's Insurance Marketplace Eligibility?

What are your rights?

You have the right to appeal any final eligibility determination made by Virginia's Insurance Marketplace that relates to:

• Your eligibility to buy health coverage through Virginia’s Insurance Marketplace
• The amount of Advanced Premium Tax Credits you are eligible to receive
• The amount of Cost Sharing Reductions you are eligible to receive
• Your eligibility for a Special Enrollment Period
• Your eligibility for Medicaid or FAMIS*

*Appeals of Medicaid and FAMIS eligibility decisions may only be appealed to the Virginia Department of Medical Assistance Services (DMAS). Please see the “Appeals of Medicaid and FAMIS Eligibility” section below for instructions regarding Medicaid and FAMIS appeals.

Appeals and Rights Instructions:

•  Consumer Appeal Request Form (English)
• Consumer Appeal Request Form (Spanish)

Timeframe to Request and Appeal (The Marketplace)

• Marketplace appeals must be submitted 90 days from the date of the eligibility determination notice you wish to appeal.

Timeframe to Request and Appeal (Medicaid or FAMIS)

• Appeals of Medicaid or FAMIS Eligibility must be submitted directly to the Department of Medical Assistance Services (DMAS)
• Appeals of Medicaid and FAMIS eligibility must be submitted to DMAS 30 days from the date of the eligibility determination notice you wish to appeal. There is an additional 5 days allowed for mailing. You must appeal directly to DMAS.  The Marketplace does not adjudicate Medicaid appeals.

Please note: If you have an immediate need for health services and a delay could seriously jeopardize your health, you can ask for an expedited (faster) appeal review.

How to submit an appeal with the Marketplace? 

You can submit an appeal through your Marketplace account, by mail or by phone. 

Online:

1. Locate the Consumer Appeal Request Form here
2. Fill out the form with all required information including, name, address, and detailed reason for you appeal. (If you are a requesting an appeal on behalf of someone else, like your child, also include their name as well.)
3. Electronically sign the form and save as a PDF. 
4. Log into your Marketplace account
5. Click "My Tickets" on your Dashboard
6. Click "Submit New Ticket" to create a new appeal ticket and attach appeal document to the ticket. You can also attach any supporting documents you believe will help your appeal to the ticket as well.
7. Submit the ticket

Mail:

1. Print out the Appeal Request Form here
2. Fill out all required information on the appeal form including detailed reason for appeal request
3. Mail in appeal request form as well as copies of any support documents to:

                                                     ATTN: APPEALS 

                                                       P.O. BOX 428

                                               Birmingham, AL 35201

Phone:

Call the Marketplace Customer Service at (888) 687-1501. Marketplace Customer Service representatives cannot provide legal advice, but they can answer questions about filing appeals and even assist with completing an Appeal Request Form.

What happens next?

After you submit your Appeal Request Form, the Marketplace will contact you to let you know whether we have everything we need to process your appeal. Once we have everything required, we will review your appeal and notify you of our decision, along with any next steps.

Informal Review: A representative from the Marketplace will contact you to attempt to resolve your appeal. If you do not agree with the outcome of the informal review, you may request to escalate your appeal to a formal hearing instead. Most consumer appeals are resolved to the consumer’s satisfaction through the informal review.

Formal Hearing: If you choose not to participate in the informal review process or are unable to resolve your appeal during that phase, a representative will contact you to schedule your appeal hearing and will confirm the date and time of your hearing in a written Notice.

Withdrawal of an appeal: You may cancel or end your appeal any time before the hearing officer issues a decision – this is known as a withdrawal of an appeal.

Representation during an appeal : You have the right to have a representative, including a lawyer, help you with your appeal. The Marketplace will not provide a lawyer for you. Your representative is a trusted person you choose who has your permission to discuss your appeal with the Marketplace, see your information, and act for you on matters related to your appeal, such as signing your Appeal Request or making arguments on your behalf at the hearing. If you want to have a representative participate in your appeal, you must either designate that person on your Appeal Request Form or submit a request to designate a representative in a separate document.

Appeals of Medicaid and FAMIS Eligibility

In addition to the Marketplace appeals process above, you can appeal a Medicaid or FAMIS eligibility decision to the Department of Medical Assistance Services (DMAS). Ways to ask for a Medicaid appeal with DMAS:

• Online at https://dmas.virginia.gov/appeals or email to appeals@dmas.virginia.gov
• By fax. Fax your appeal request to DMAS at (804) 452-5454
• By mail or in person. Send or bring your appeal request to Appeals Division, Department of Medical Assistance Services, 600 E. Broad St, Richmond Va 23219
• By phone. Call DMAS at (804) 371-8488 (TTY: 1-800-828-1120)

To help you, a Medicaid Appeal Request Form is available from DMAS at https://www.dmas.virginia.gov/appeals/.You can also write your own letter. Include a full copy of your eligibility determination notice when you file your appeal. Also include any documents you would like DMAS to review during the appeal.If filing an Appeal by mail consumers have 30 days, plus 5 for mailing from the date on the notice to submit an appeal request to DMAS.The standard decision timeframe is 90 days from the date you filed your appeal request. If you have any questions about Medicaid appeals, call the Appeals Division of DMAS at (804) 371-8488 (TTY: 1-800-828-1120), or visit https://www.dmas.virginia.gov/appeals/applicant-member-appeals-resources/ for more information. To learn more about getting free legal advice or to ask for someone to represent you in your appeal case, call the free Legal Aid Helpline at 1-866-534-5243 or visit www.valegalaid.org.
If it's been more than 90 days since you got your Eligibility Notice, explain why you missed the deadline when you file your appeal. You may be able to get an extension.