Informal Review Process – Account Review Unit
If you disagree with your eligibility determination you can ask for an informal review of the determination by the Marketplace when you request an appeal or any time before your appeal hearing is held. The informal review process gives you the opportunity to explain why you disagree with your eligibility determination, to provide any information that you think was missing when the determination was made and for the Marketplace to review your account to see if a mistake was made in your eligibility determination.
If the Marketplace agrees with you that your eligibility determination should be corrected, it can make that correction and you will not need to continue to an appeals hearing. If the Marketplace cannot correct your determination, you can continue with the appeals process and have a hearing before an independent hearing officer.
An Appeal Hearing is a formal process in which you tell an impartial Hearing Officer why you think a determination NY State of Health made on your application for health insurance is wrong. After the hearing, the Appeals Unit will issue a written decision that will say whether NY State of Health’s determination was right or wrong. The decision may tell NY State of Health to correct the determination that it made.
Fast-tracking (Expediting) your appeal
In your request, you must say why you need to fast-track it. For example, if your health is likely to get much worse with the normal wait for a hearing, you should ask us to fast-track the process. You must send us a note from your doctor backing up your reason(s) for needing to fast-track your Appeal.
If we accept your fast-track request, we will set a date for your Telephone Hearing as soon as possible.
If we deny your fast-track request, we will tell you, in writing, why we denied it. We will also tell you when your Telephone Hearing will be held and all your rights at the Telephone Hearing.
How to keep your health coverage during the appeal process
If you are covered by Medicaid…
…your health care coverage will continue during the appeal process as long as you ask for aid-continuing and request your appeal either
- before the effective date of the Notice stopping or reducing your Medicaid coverage; or
- within 10 days of the mailing of the Notice stopping or reducing your Medicaid coverage if the Notice arrives after the effective date.
You can appeal this decision within 60 days of the Notice date, but coverage will stop or change if you do not ask us to continue your Medicaid.
If you are covered by any other health plan bought through the Marketplace…
…your health care coverage will continue during the appeal process as long as you ask for your plan to continue and request an appeal within 60 days of the date on the Notice of determination you are appealing.
How to appoint a representative appeal process
You have the right to choose a representative to help you with your appeal. If you want to appoint an appeal representative, complete and submit the Appoint a Representative for My Appeal Form.