California Covered: How to Complete the Employer Appeal Request

What to do if you receive a Marketplace Notice

WHAT DOES THE NOTICE MEAN?

If any of your employees (including part time employees) received a premium tax credit for enrolling in a qualified health plan through Covered California, you will likely receive a Marketplace Notice.

If you received a Marketplace notice stating that you may be subject to the Employer Shared Responsibility Payment, you can file an appeal to 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.

The appeal process will only asses if the employee’s coverage qualifies for Employer Shared Responsibility payment - it will not determine the amount of fee - only the IRS can assess fee amounts.

APPEAL FILING INSTRUCTIONS

If you believe that your coverage meets the requirements and that you are not subject to a Employer Shared Responsibility payment, this will be the only opportunity to appeal. The appeal must be submitted for each employee in question within 90 days.

We recommend providing documentation along with the completed Employer Appeal notice and a letter prior to the end of the 90 day period.

Download and complete the appeal form. The appeal form can be downloaded here

Mail or fax the completed form along with a cover letter and supporting documentation:

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

OR

Secure fax line: (877)369-0131

Step 4 of the appeal asks you to provide an explanation of why the employee should not be eligible for a premium tax subsidy.

We recommend that employers complete this section by providing details explaining that the employee either:

  • Did not qualify as full-time due to less than 30 hours/week on average.

or

  • Was offered qualified coverage

SUPPORTING DOCUMENTATION

The notice also provides a link to an Employer Appeal Document guide which provides guidance on submitting documentation to support the appeal explanation listed in step 4.

The following documents will help to support your determination of subsidy ineligibility:

  • The completed Employer Appeal Notice

  • A letter advising the appeal was received and the information being included. You may want to include if the employee was benefit eligible, offered coverage, accepted or declined coverage, etc.

  • Offer of Coverage Letter – this can be a copy of the letter included in the benefits packet that is distributed to benefit eligible employees

  • Benefits of Summary Chart – screenshot of the decline or enrollment in coverage (this can be a screenshot from an electronic enrollment system)

  • Summary of Benefits and Coverage Sheet (SBC) – include a copy of the SBC for the LOWEST cost plan only

  • Rate sheet for employer sponsored plan – screenshot of the LOWEST cost plan (this can be a screenshot from an electronic enrollment system)

  • Include information on the measurement period dates and the results

  • History of measurement hours by pay period for each measurement period

  • Identify employee’s date of hire; if they are terminated or had any break in service include details

  • Income information i.e. employee’ pay stubs, payroll ledger or worksheet, employee’s W-2

  • 1095 showing coverage was offered if employee was benefit eligible ( includes information if employee was in the waiting period or terminated)

After the appeal is submitted you will receive a letter saying the appeal was received.  It will provide a description of the appeals process and instructions for submitting additional materials if needed.


If you still have questions or require additional assistance, please contact us and we would be happy to help!