Marketplace Definitions and Explanations

Definition & Explaination

Casework:  Issues that the Marketplace Call Center or CMS receives directly from the consumer that require CMS to research or review. 

CMS Casework handles: 

  • Approving or denying exceptional circumstance SEPs;
  • Resolving 1095 A tax form and other complex issues;
  • Referring cases to insurers, providing technical assistance to insurers and monitoring insurer cases for staleness and trends; and
  • Informing consumers of resolution, appeal rights, and next steps

Marketplace Eligibility Appeals:  An appeal is a legal action consumers can take when they receive a final eligibility decision from the FFM and they do not agree with the decision. Consumers generally have 90 days from the date an eligibility determination is made to appeal the decision. 

To make your appeal, start by reviewing the Marketplace’s decision. You will have received the decision (called a determination notice) online if you initially applied online, or in the mail if you submitted a paper application. So far, in the federal Marketplace, the notice will not provide much detail to explain the reasons for the decision, but it will describe the process you should follow if you want to appeal. To request an appeal in federal Marketplace states, you’ll have to submit the appeal in writing.  You can write a letter or use appeal forms available on healthcare.gov. Your written appeal should provide your name and contact information and an explanation of what you are appealing and why.
 
You can submit documents to the Marketplace that support your case. You can submit documents along with your initial appeal request or at any time during the appeal process, up until a hearing.

The Marketplace may offer you the option of receiving temporary benefits while your appeal is pending. You can accept the temporary benefits or waive them. If you accept temporary benefits during the appeals process and then lose your appeal, you might have to pay back the benefits you weren’t eligible for.

The Marketplace will review your completed appeal once it is submitted. Then the Marketplace will let you know its decision.  If you still disagree with the decision, you can request a hearing. While you are waiting for the hearing to take place, the Marketplace may contact you to try to resolve the dispute informally.

Appeal to the Insurer: An appeal is the process consumers use to have their plan's benefits or insurer's decsions reviewed.  Appealable issues include problems access benefits or coverage cancellation.

What types of issues that can be resolved through the insurer?

  • Provider was listed as in-network, but when attempting to use coverage, the provider doesn't accept the consumer's insurance
  • Went to the emergency room and the consumer's bill says the provider was out-of-network and payment is owed
  • Insurer denied a claim for a covered service or procedure

Office of Superintendent of Insurance of New Mexico (OSI)

Consumers can file a complaint with OSI if they are not satisfied with their insurer's appeal decision, believe an insurer's actions are discriminatory or unfair, or believe they have been fraudulently sold health insurance. 

Getting Help With Appeals

Consumers can get help with Marketplace eligibility appeals by:

Calling 1 (800) 318-2596 and TTY users call 1 (855) 889-4325

  • Navigators/Enrollment Counselors can help consumers ask for a Marketplace eligibility appeal
  • Appointed representative can request a Marketplace eligibility appeal and speak for the consumer
    • Must be designated in writing, signed by the appellant
    • Contact Marketplace Appeals Center for more information
      • Call 1(855) 231-1751 TTY users call 1(855) 739-2231
         

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