You have the right to file an appeal of any final eligibility determination from Pennie.  You can appeal, among other things, a decision to deny, terminate, or change:

  • Your eligibility to buy health coverage through Covered California.
  • The Advanced Premium Tax Credits (including the dollar amount of your tax credit) you are eligible to receive
  • The cost-sharing reductions (including the dollar amount of your cost-sharing reductions) you are eligible to receive
  • Your ability to enroll in or change plans through Covered CA outside of an open enrollment period
  • The insurance you can buy because Covered CA told you that you did not submit documents proving that you were ineligible for other types of health coverage
  • Covered CA did not provide you with a timely eligibility determination after you applied for insurance coverage

Please note, only final Eligibility Determinations of the Exchange are appealable.  At times, some notices from the Exchange are not final Eligibility Determinations and cannot be appealed.  These include, but are not limited to the following:

  • If you receive notice that says that someone in your application needs to submit documents, then you must follow instructions for sending them. Until you submit documents and your issue is resolved, your eligibility notice is not a final Eligibility Determination and cannot be appealed.
  • If you are required to send more information to the state Medicaid or CHIP agency, your eligibility notice is not a final determination of eligibility for Medicaid or CHIP coverage and it cannot be appealed.

 

You have 90 days from the mailing date of a notice to file an appeal. 

 

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. (See step 5)

 

Your appeal should be in writing and must include your name, address, and a detailed reason why you believe the Exchange’s eligibility determination is in error.  If you are requesting an appeal for someone else (like your child), also include their name.

 

·       Any decision about your eligibility for benefits may also change the eligibility of other people in your household.

·       All appeals from actions of the Office are governed by 45 C.F.R. §§ 155.10, et seq. and the General Rules of Administrative Practice and Procedure, 1 Pa. Code § Part II, Chapters 31-35.

To find more information on how to appeal a decision please visit www.coveredca.com/appeals for more information and to download an appeals form.