- What if I disagree with a determination made by NY State of Health?
You can call us at 1-855-355-5777 (TTY: 1-800-662-1220) to discuss your concerns and we will do our best to help you. If you are not satisfied with the result of the informal resolution process you may request a formal appeal, if the time limit for requesting an appeal has not ended. Or you can ask us for an appeal without using the informal resolution process.
- What is an appeal?
An appeal is a formal request to have a review of your eligibility determination because you do not agree with the one NY State of Health made. You can request an appeal for yourself and anyone in your household who also applied for health insurance.
Once you request an appeal, NY State of Health will schedule a hearing. A hearing is a formal conversation where you will have the opportunity to explain why you disagree with the eligibility determination we have made. An impartial hearing officer will conduct your hearing. If you have documents that you think would help your appeal, you can submit them for the hearing. During the hearing, you can also explain why you think we made a mistake.
- What can I appeal?
You can appeal determinations made by NY State of Health including:
Your eligibility for Medicaid, Child Health Plus, or the Essential Plan
The amount of financial assistance you will receive toward your monthly health insurance premium
The amount of financial assistance you will receive toward your out-of-pocket expenses when you use health care services
A denial for a special enrollment period; and
Whether we made a timely eligibility determination
- Where do I go to appeal a decision about my health care services?
NY State of Health cannot accept appeals about health care services such as the types of health care benefits your plan offers, access to doctors or specialists, or a denial of prior authorization for services.
If you are covered through Medicaid, please contact the Office of Administrative Hearings at www.otda.ny.gov/oah/ or at 1-800-342-3334 to appeal coverage decisions.
If you are covered through the Essential Plan, Child Health Plus or are enrolled in a Qualified Health Plan, please contact your health plan to appeal coverage decisions. Information on health insurance complaints and appeals can be found on the Department of Financial Services website at https://www.dfs.ny.gov/consumers/health_insurance/your_rights_as_a_health_insurance_consumer.
- Are there time limits to file an appeal request?
Yes, there are time limits. Generally, you have 60 days to request an appeal. Once NY State of Health has received your appeal request, we will review it and let you know what happens next.
- Where do I go for my hearing?
NY State of Health conducts all hearings by telephone and will call you at the telephone number(s) you provided in your NY State of Health account. If you want us to call you at a different number, you may give us that number in your NY State of Health account or when you call us to request the hearing.
When you request a hearing, you can let us know which day of the week and time (morning or afternoon) is convenient for you. We will do our best to schedule your hearing on the day and time that works for you. After we receive your appeal request, we will send you a scheduling notice to let you know when we will call you for your hearing.
- What if I need special assistance or accommodations for my hearing?
You can request for special assistance or accommodations for your hearing. This includes language assistance (such as translation from English to another language) and accommodation for any hearing impairment.
- Can I have someone help me at my hearing?
Yes. You can have a lawyer, relative, or friend help you during the appeal process. If you think you need a lawyer, you might find one at no cost by calling your local Legal Aid, Legal Services Office, or local Bar Association. You can also represent yourself.
If you want help during your appeal, you can designate a person or an organization to act as your authorized representative. Your authorized representative receives the same appeal notices and other communications that you do.
- What can I do after I submit my appeal request?
While you are waiting for your hearing to be scheduled, we can help you try to resolve your problem informally. You can also provide new information or documents that will help us understand your concerns during the informal process. To do so, you can call us at 1-855-355-5777. If we have resolved your concerns during this informal process, we will then work with you to withdraw the request.
- Can I continue my coverage during the appeal process?
Yes, but it is optional. If you are enrolled in Medicaid, the Essential Plan, Child Health Plus or a Qualified Health Plan, you may be able to continue the same coverage or amount of financial assistance during the appeal process. Financial assistance includes aid you received to pay for your health insurance premiums or to reduce out-of-pocket costs when you use health care services.
If you have Medicaid, you need to act quickly. You have ten (10) days from the date of your eligibility determination notice to ask us to have your Medicaid continued during your appeal process.
- How will the appeal decision affect me or other people in my household?
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.
- What should I do if I no longer want to appeal?
If you have requested an appeal and feel it is no longer necessary, you may withdraw your appeal request. Call NY State of Health at 1-855-355-5777 to learn how to withdraw.