Questions about Appeals

The NY State of Health Appeals Unit is a team of attorneys and support staff who process appeals from the NY State of Health Insurance Marketplace and the newly created Medicaid Eligibility Client Management system (MECM). The same unit hears and issues dismissals/decisions on issues arising from notices issued by both systems. The attorneys act as impartial adjudicators (aka Hearing Officers or Administrative Law Judges) to determine whether or not the actions taken by NY State of Health regarding an individual’s eligibility for health insurance, including with financial assistance, were proper.

The NY State of Health Appeals Unit hears issues regarding notices sent by NY State of Health. These notices may be determinations about eligibility, denial, or discontinuance. Issues may include:

• That you or someone in your household does not meet the rules to enroll in a Qualified Health Plan
• That you or someone in your household meets the rules to qualify for Advanced Payments of the Premium Tax Credit (APTC); cost-sharing reductions; the Essential Plan; Child Health Plus; MAGI Medicaid; certain Non-MAGI Medicaid programs; and the Medicare Savings Program
  • Currently, NY State of Health is only determining eligibility for Non-MAGI Medicaid without long-term care (this includes individuals who are age 65+ or older, certified disabled, or have Medicare and do not require services in their home or nursing home coverage).  Going forward, NY State of Health will transfer additional populations in waves, and the appealable issues heard by the NY State of Health Appeals Unit will expand to include these populations.
• The amount of APTC and/or level of cost-sharing reductions for which you or someone in your household may be eligible
• The Essential Plan level for which you or someone in your household may be eligible
• How much money you or someone in your household must pay for Child Health Plus coverage
• That you or someone in your household does not meet the rules for enrolling through NY State of Health during Open Enrollment or a Special Enrollment Period
• That NY State of Health did not issue a timely determination of your eligibility. Example: You did not get a notice telling you if you meet the rules for Medicaid coverage within the required 45 days.

The Office of Temporary and Disability Assistance (OTDA) will continue to hear issues regarding denial/discontinuance notices from the Local Department of Social Services (LDSS) and Human Resources Administration (HRA), as well as service appeals (e.g., denial of medical treatment, equipment or services). OTDA and the NY State of Health Appeals Unit will work together to ensure appeals are filed in the proper venue. 

You must request an appeal within 60 days from the date on the notice you disagree with. If your request is outside the 60 days, the NYSOH Appeals Unit will send you a letter asking you to submit a good cause reason why your appeal request was not within the 60-day window. 

You can appeal by calling: 1-855-355-5777.

You can also file your appeal on paper either by writing us a letter, or submitting this printable request form found here. 

Complete the printable Appeal Request Form and return it by mail, fax, or upload it to your NY State of Health account.

You may mail the form to the following address:

NY State of Health
Appeal Unit
P.O. Box 11729Albany, NY 12211

You may also fax the form to 1-855-900-5557.

Please let us know if you want an interpreter, and what language you need. NY State of Health Appeals Unit will provide an interpreter in your preferred language during your hearing.  This is at no cost to you.

If you require a special accommodation, please see the Special Accommodation section below.

If you have coverage, you can ask to keep it while you go through the appeals process. This means that your current insurance program will continue until a decision is made about your appeal.

If you have Medicaid coverage, NY State of Health will continue your coverage if you request it within 10 days from the date of the notice OR before the eligibility effective date listed in the notice, whichever is later.

Please note: If the outcome of the appeal is not in your favor, you may be responsible for the cost of the health coverage that you used while your appeal was pending.

If you received coverage through Medicaid while your appeal is being determined, you may have to pay back the cost of Medicaid benefits you received. If you were enrolled in the Essential Plan or Child Health Plus while your appeal was being determined, you may have to pay back your premium, if you have a premium. If your appeal found that you are not qualified for tax credits, the IRS will reconcile your tax credits when you file your federal tax return, which may result in a tax penalty.

Before an appeal is filed, customer service will try to resolve your issue through an informal review. The informal review allows you to explain why you disagree with your eligibility determination, to provide information that you think was missing when the determination was made, and for NY State of Health to review your account for any mistakes that may have been made in your eligibility determination.

For issues concerning Non-MAGI Medicaid (Medicaid without long-term care -- this includes individuals who are age 65+ or older, certified disabled, or have Medicare and do not require services in their home or nursing home coverage) and the Medicare Savings Program, you may request an agency conference with someone from NY State of Health.  During this process, you can ask questions and try to resolve the issue before the hearing. You can request an agency conference by calling customer service at 1-855-355-5777.  Ask to speak to the Account Review Unit.

Before your hearing, NY State of Health will put together an Evidence Packet.  The packet may include documents and screenshots from your NY State of Health account, and other information regarding your eligibility determination and NY State of Health’s decision-making process. The packet will be available in your NY State of Health account five days after you receive the scheduling notice for your hearing. If you want a copy of your evidence packet by mail, or if you would like other information to prepare for your hearing, call customer service at 1-855-355-5777.

Yes. Documentation you want the Hearing Officer to review can be uploaded to your NY State of Health account. Customer service can help you upload this documentation.

If you do not have access to your NY State of Health account, you may also submit documentation by mail or fax.

• Supporting evidence can be faxed to 1-855-900-5557
• Supporting evidence can be mailed to:

NY State of Health
Appeal Unit
P.O. Box 11729
Albany, NY 12211

If submitting evidence by mail or fax, please clearly indicate on the documentation that it is for an APPEAL, the appeal number, and the account/case number.

The Hearing Officer may also request that you submit documentation after your hearing, the Hearing Officer will give instructions on submitting additional evidence during your hearing.

If you have an immediate need for health insurance and a delay would seriously jeopardize your life, health, or ability to gain, maintain, or get back maximum function, you can ask for an expedited (faster) appeal.

Please call customer service at 1-855-355-5777.  Ask to speak with the Account Review Unit how to request an expedited appeal.

You must request an expedited appeal in writing. You must include medical documentation from your medical provider that explains/supports why you need your appeal expedited.

The Appeals Unit will determine if your hearing should be expedited after it receives your documentation.  Customer service will contact you with a decision on your request.

Generally, the hearing will be a formal conversation between you and a Hearing Officer from the NY State of Health Appeals Unit. You can appoint an appeals representative, such as a friend or a family member, or you can have an attorney represent you. You also have the right to call any witnesses you want.

NY State of Health Appeals Unit will provide an interpreter at no charge, if needed.

For issues concerning Non-MAGI Medicaid (Medicaid without long-term care -- this includes individuals who are age 65+ or older, certified disabled, or have Medicare and do not require services in their home or nursing home coverage) and the Medicare Savings Program, the Hearing Officer may require NY State of Health to attend the hearing. This means a NY State of Health agency representative will also be on the phone. You may ask the NY State of Health agency representative questions.

To appoint a non-attorney appeal representative (like family members, friends, or assistors), you must submit form DOH 5232 (found here ).

To appoint someone from a legal services/attorney’s office, you must submit a letter on the organization’s letterhead.  The letter must confirm that you are being represented and include their phone number to reach the person who is appearing at the hearing on your behalf.

You can upload the DOH 5232 form or letter to your NY State of Health account, or send it by fax (1-855-900-5557) or mail (NY State of Health, Appeal Unit, P.O. Box 11729, Albany, NY 12211).

If the Hearing Officer does not have your DOH 5232 form or an attorney letter with contact information at the time of your scheduled hearing, the Hearing Officer will call you at the phone number you provided.  You can verbally appoint someone to represent you at that time. If your chosen representative is unavailable, you may request a one-time adjournment. Your hearing will be rescheduled so that your representative has notice.

About two to three weeks before your scheduled hearing, you will receive a notice of a telephone hearing in the mail. A copy of this notice will also be uploaded to your NY State of Health account. Hearings are conducted Monday through Friday, at 9:00 a.m., 10:00 a.m., 11:00 a.m., 1:00 p.m., 2:00 p.m., or 3:00 p.m. The Appeals Unit will do its best to schedule your hearing on your preferred day/time.

All hearings conducted by the NY State of Health Appeals Unit are done by telephone through a recorded line. The Hearing Officer will call and conference in all relevant parties to the appeal. This includes yourself, interpreters, and representatives.

When you file an appeal, you and/or your representatives will be asked if there is any sort of accommodation that you need. The NY State of Health Appeals Unit utilizes text telephone (TTY) technology from the New York Relay Service as an accommodation to conduct hearings with hearing-impaired individuals.  For appellants or representatives with a disability that prevents them from participating in a hearing by telephone, a reasonable accommodation may be requested.   

If it is an accommodation that the Appeals Unit does not already offer, we will ask you to make a reasonable accommodation request. This request should be in writing. It must describe the accommodation and why it is medically necessary. The NY State of Health Appeals Unit will then review the documentation you have submitted and determine if your request can be accommodated.

If you do not have access to a personal telephone, the NY State of Health Appeals Unit will communicate with you in writing.  You will be given other options, including different locations with a phone to use for the hearing.

If you no longer need your telephone hearing (for example, your issue was resolved), please call customer service at 1-855-355-5777.  Ask to speak with the Account Review Unit. You can also upload, mail, or fax a written withdrawal. Please indicate that you no longer wish to continue your appeal, your account/case number, and your appeal number.

You can mail your withdrawal to:

NY State of Health
Appeal Unit
P.O. Box 11729
Albany, NY 12211

Or fax it to 1-855-900-5557.

You can also tell the Hearing Officer that you no longer wish to continue your appeal at the time of the hearing. The Hearing Officer will swear you in and ask you to withdraw your appeal verbally.

NY State of Health Appeals Unit will send you a letter confirming that you want to withdraw your appeal. If you change your mind and still need a hearing, the letter will tell you how to cancel your withdrawal and continue your appeal.

If you are unable to attend your telephone hearing, please call customer service at 1-855-355-5777 and ask to speak to the Account Review Unit as soon as possible.

You can also request a reschedule/adjournment directly from the Hearing Officer when they call you for your scheduled hearing.

At the scheduled hearing time, a Hearing Officer from the NY State of Health Appeals Unit will call you, your representative (if applicable), an interpreter (if needed), and the NY State of Health representative (if applicable). If you do not answer the phone, the Hearing Officer will leave a voicemail if possible.  They will attempt to call you twice more. Once the Hearing Officer has all necessary individuals on the phone, they will swear you in and explain the hearing process. You will be allowed to explain your situation.  The Hearing Officer will ask questions to develop the record. If an agency representative is on the phone, they will also have the opportunity to explain their position. You can ask the agency representative questions, and they can ask you questions. If the Hearing Officer requires additional documentation from you, the record will be left open.  You will be given instructions on how to submit additional documentation, if needed.

Once the record closes (meaning the Hearing Officer has all the information necessary to make a final decision), they will write a decision. The decision will be mailed as paper copy by regular mail and uploaded to your online account. The decision is also provided to the agency. The decision may have additional instructions for you or the agency to follow.

If you miss your telephone hearing, the NY State of Health Appeals Unit will mail you a notice.  It will have instructions on how to reschedule your hearing. If you do not get a notice in the mail, please check your NY State of Health account or call customer service at 1-855-355-5777.

If your appeal is successful, NY State of Health will be required to take specific action on your account as directed by the Appeals Unit.

If you believe NY State of Health has not acted after your hearing decision, you may contact customer service at 1-855-355-5777.

For issues concerning Non-MAGI Medicaid (Medicaid without long-term care-- this includes individuals who are age 65+ or older, certified disabled, or have Medicare and do not require services in their home or nursing home coverage) and the Medicare Savings Program you can also request a process called Compliance.

In addition to calling customer service at the number above, you may also write a letter to us asking for Compliance and mail it to:

NY State of Health
Appeal Unit
P.O. Box 11729
Albany, NY 12211

You may also fax the request to 1-877-881-5714.

If necessary, NY State of Health Appeals Unit will follow up with the agency. You will be informed of the status.

Appeals Unit decisions on issues regarding eligibility for Qualified Health Plans, APTC, and cost-sharing reductions may be appealed to the Federal Marketplace. This must be done within 30 days of the decision date.

If you have questions about appealing to the Federal Marketplace, you can contact them in any of the following ways:

• By calling the Customer Service Center at 1-800-318-2596
• By fax: 1-877-369-0129
• By mail at:

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

For issues concerning Non-MAGI Medicaid (Medicaid without long-term care -- this includes individuals who are age 65+ or older, certified disabled, or have Medicare and do not require services in their home or nursing home coverage) and the Medicare Savings Program, you can ask for Reconsideration. Reconsideration is an internal process in which the Appeals Unit will review the closed record from your hearing. The Appeals Unit will determine if the Hearing Officer who conducted your appeal made a mistake of law or fact.

You may write a letter to us asking us to Reconsider your appeal and mail it to:

NY State of Health
Appeal Unit
P.O. Box 11729
Albany, NY 12211

You may also fax the request to 1-877-881-5714.

Please note that the agency also has the right to request Reconsideration. If the Appeals Unit grants the agency’s reconsideration request, you will receive a letter in the mail that allows you the opportunity to respond to the agency’s request.

You may also bring a lawsuit on any Appeals Unit decision in New York State Court in accordance with Article 78 of the New York Civil Practice Law and Rules. This must be done within 4 months of the decision date. The decision date appears on the first page of your hearing decision notice.

Depending on the appeal decision, you may have to repay some or all of the financial assistance you received during the appeal process. If we determined other people in your household eligible for health insurance through NY State of Health, their eligibility may also change. NY State of Health will let you know of the changes and redetermine the eligibility for you and your household, if applicable.