Lessons from CA: Exchange Eligibility Appeals under the Affordable Care

Executive Summary

Section 1411(f) of the Affordable Care Act requires the HHS Secretary to establish an appeals process related to eligibility determinations made by Exchanges, including among other things, eligibility for enrollment in a QHP and eligibility for premium tax credits and cost-sharing reductions. The federal Department of Health & Human Services (HHS) published final rules on August 30, 2013 that address the notice and hearing requirements for these eligibility appeals as well as obligations of the Exchange appeals entities who hears these appeals (and the relationship between Exchange appeals and Medicaid/CHIP appeals).