The Marketplace Appeal Request Form allows you to dispute an eligibility decision by the Health Insurance Marketplace. If you disagree with a ruling about your coverage, financial help, or enrollment timing, this document lets you present your case to an independent reviewer. You have 90 days from the date on your Marketplace Eligibility Notice to submit it.
The document requires personal details for everyone whose eligibility is affected. It asks you to identify the exact decision you want to challenge and explain your reasons. You can request an expedited review if you have an urgent medical situation that cannot wait for the standard timeline.
If you need help during the process, you can appoint an authorized representative to act on your behalf. Supporting documents, such as pay stubs, tax returns, or medical records, strengthen your case. All signatures carry legal weight and confirm that the information you provide is accurate.
Related documents on FormsPal include the general appeal form for broader use, the Aetna appeal form for Aetna policyholders, and the Cigna appeal form for Cigna plans. If your complaint involves a different type of dispute, consider the grievance form instead.
| Question | Answer |
|---|---|
| Form Name | Appeal Request Form |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Filing Deadline | 90 days from Marketplace Eligibility Notice |
| Issuing Authority | Health Insurance Marketplace (healthcare.gov) |
| Other names | appeal request form pdf, healthcare appeal form, fema appeal form, insurance appeal form pdf |