Appeal Request Form – Individual (
09/2020
)
Instructions to help you complete the
Marketplace Eligibility
and Financial Assistance
Appeal Request
Use th
is
form to
request an appeal
•
Complete and mail this request form for your appeal.
•
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).
Time frame to
request an appeal
Yo
u must submit your appeal request
within 90 days
of the date on the eligibility
determination notice that you are appealing.
How to submit this
form
Enter your information directly, then print your completed form. Or, print a blank form to
fill in by hand using black or dark blue ink.
Sign the completed form and mail together with any supporting documents to:
Get Covered New Jersey
Attn: Appeals
PO Box 55898
Trenton, NJ 08638
What happens
next?
1.
We will send you a notice letting you know that we received your appeal
request and if anything is missing.
2.
We will reviewyourappeal,includingalldocumentationyouhave provided.
We may contact you to request additional information or to discuss your
appeal.
3.
We may ask if you want to resolve your appeal informally. If you are satisfied with
your informal resolution, you will get an informal resolution decision in the mail.
4.
If you are not satisfied with your informal resolution, you can ask us to
schedule a hearing for your appeal.
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Most hearings are held over the phone. If you
don’t attend your hearing, your appeal will be dismissed.
5.
After your hearing, you will get a final appeal decision.
Appeal Request Form – Individual (
09/2020
)
To appoint an authorized representative, complete DQGmail the form “Appoint an
authorized representative for my appeal,” at the bottom of this application. if you
already completed an authorized representative form for your Marketplace
application, you need to complete an additional form for your appeal.
Language assistance services
If you need help with your appeal in a language other than English,
you have the right to get information in your language at no cost. Call
the Call Center at 1-833-677-1010.
Accessibility
If you need assistance with accessing appeals forms, you can contact the Call Center at 1-
833-677-1010. TTY users can call 711. You can also make a request in writing by mai
l
(
Get Covered New Jersey, Attn. Appeals, P.O. Box 55898, Trenton, NJ 08638).
Accommodations are provided at no cost to you.
Choose an
Authorized
representative
To submit your appeal request, see “How to submit this form” on page 1 of these
instructions.
You have the right to choose an authorized representative to help you with
your
appeal. This is a trusted person who has your permission to talk with us
about your appeal, see your information, and act for you on matters related to your
appeal, including getting information about you and signing your appeal request
on your behalf.
Privacy and Use of Your Information
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Nondiscrimination
Get Covered New Jersey doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis
of race, color, national origin, disability, sex, or age. If you think you’ve been discriminated against or treated unfairly
for any of these reasons, you can file a complaint by contacting the GetCoveredNJ Call Center 1-833-677-1010 (TTY:
711) or with the U.S. Department of Health and Human Services, Office for Civil Rights by calling 1-800-368-10
19
(
TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights, U.S.
Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington,
D.C. 20201
To learn more about your appeal, contact the Call Center at 1-833-677-1010.
TTY users can call 711.
Additional help
Appeal Request Form – Individual (
09/2020
)
To help the Marketplace Appeals Center process your appeal, refer to the table below about the types of documents to
submit with your appeal request.
Submit copies and not original documents, since your original documents will
not be returned
. Write your first and last name on any documents you send with your appealrequest.
Reason you are appealing Examples of supporting documents to include with your appeal request
You lost financial assistance for your
Marketplace coverage because the
Marketplace told you that you did not
submit documents proving your
household income.
•
Tax returns (e.g. 1040, 1040A, 1040EZ)
•
Pay stubs, W-2s, or 1099s
•
Self-employment ledgers (including the name of the person earning the
income, the company’s name, the dates for which the income is
received, and the net amount of profit or loss)
•
Social security benefits statements
You lost financial assistance for your
Marketplace coverage because the
Marketplace told you that you did not submit
documents proving that you were ineligible
for other types of health coverage.
•
Medicaid – letter from your state’s Medicaid agency or Children’s Health
Insurance Program (CHIP) stating you are not eligible for Medicaid or CHIP
•
Department of Veterans Affairs (VA) – letter from VA stating you are not enrolled
in health coverage
•
Employer coverage (including COBRA) – letter from health insurance company or
employer stating you were ineligible or showing termination information
•
TRICARE – letter from Department of Defense Health Agency statingyou are not
eligible for health coverage
•
Peace Corps – letter from Peace Corps stating you are not eligible for health
coverage
•
Medicare – letter from the Centers for Medicare & Medicaid Services (CMS) or
Social Security Administration (SSA) stating you are not eligible for Medicare
You lost your coverage because the
Marketplace told you that you did not
submit documents proving your
citizenship or immigration status.
•
Permanent Resident Card (I-551)
•
Employment Authorization Card (I-766)
•
United States and Unexpired Foreign Passports
•
Driver’s Licenses or State ID along with US Birth Certificate
•
Notice of Action(I-797)
•
Departure Record (I-94)
•
Certificate of Citizenship (N-560/N-561)
•
American Indian Card (I-872)
•
School records showing the child’s name and U.S. place of birth
along with a school photograph ID
The Marketplace told you that you were
not eligible to enroll in or change plans
through the Marketplace outside of an
open enrollment period.
The reason you believe you should be allowed to enroll is because you:
•
Lost or are losing coverage – letter from the insurance company, or the
agency which administered the insurance, showing the last day of
coverage
•
Were denied Medicaid or Children’s Health Insurance Program (CHIP)
– denial or termination letter from NJ FamilyCare
•
Got married – marriage certificate, marriage license, or signed affidavit
•
Had a baby, adopted a child, or placed a child for foster care – birth
certificate, hospital records, adoption certificate, child support order, or
court order
•
Had a permanent move – driver’s license, state ID, lease agreement,
mortgage payment receipt, or utility bill
Appeal Request Form – Individual (
09/2020
)
()
Page 1 of
Marketplace Eligibility Appeal Request
STEP 1:
Tell us about the person requesting this appeal (also called the
“appellant”).
If other membersof your household are appealing, writetheir names and dates of birthbelow.
Use extra paper, if necessary. Note: The outcome of an
appeal could change the eligibility of other members of your household, even if they do not appeal their own eligibilitydeterminations.
Page 2 of
6
܆
Marketplace determined that I was not eligible for coverage.
܆
I lost financial assistance for my Marketplace coverage, also called advance payments of the premium tax credit or
cost- sharing reductions.
܆
I disagree with the amount of financial assistance (advance payments of the premium tax credit
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or cost-sharing reductions) that I was found eligible for.
܆
Marketplace determined that I wasn’t eligible to enroll in or change plans through the Marketplace outside of an open
enrollment period.
܆
Marketplace did not provide a timely eligibility determination after I applied for coverage.
Enter the date of your application, if available. (mm/dd/yyyy)
STEP 2:
Electronic reminders.
STEP 3:
Tell us
your preferred hearing method
.
Do you want to have your appeal:
܆
by telephone ܆
in-person at a hearing location
Do you need any assistance for your appeal hearing, including interpreter services or assistance with access or accommodations
for your full participation in the appeal? (These will be provided free of charge.) Explain below:
STEP 4: For consumers who were eligible for Marketplace coverage last year, and
are appealing a redetermination of their eligibility for a qualified health planwith
financial assistance:
STEP
5
:
Tell us why you are appealing.
Select each appeal reason that applies to you or someone in your household.
Marketplace Eligibility Appeal Request Form – Individual (
09/2020
)
Page 3 of
6
Appeal Request Form – Individual (
09/2020
)
STEP
5
:
Tell us more about why you are requesting this appeal.
Use extra paper if necessary. If you are including documents to support your request, send us one copy of each of
your documents. Keep all original documents.
Page 4 of
6
Appeal Request Form – Individual (
09/2020
)
STEP
6
:
Ask for a faster appeal if you need one.
If you have an immediate need for health services, and a delay could seriously jeopardize your life, health,
or ability to attain, maintain, or retain maximum function, you can ask for an expedited (faster) appeal review.
܆
I need an expedited appeal.
Explain the reason you need an expedited appeal. Write the reason for this request in the space below. Use extra paper if
necessary. If you’re including documents to support your request, send us one copy of each of your documents. Keep all origi
documents.
Appeal Request Form – Individual (
09/2020
)
Page
5
of
6
1. Printed name (First Name, Middle Name, Last Name)
Signature
Date (mm/dd/yyyy)
2. Printed name (First Name, Middle Name, Last Name)
Signature
Date (mm/dd/yyyy)
3. Printed name (First Name, Middle Name, Last Name)
Signature
Date (mm/dd/yyyy)
Signatures of everyone you listed in Section 1 who is 18 and older
Signature
STEP
7
:
Signature.
This information applies for all individuals signing below who are 18 or older.
Your approval to let Get Covered New Jersey share federal tax information, Social Security Administration
information, and other relevant personal information for use during an appeal.
Duringyour appeal, wemay needto share with you oryour authorized representative
and appeal authority
the information
GetCoveredNJ
used to determine your eligibility. This information might include employment income information from a
consumer reporting agency, information about income you receive from the Social Security Administration, and federal tax
information from the Internal Revenue Service about members of your household, including information from your last filed
federal income tax return. The Marketplace cannot share federal income tax information or monthly and annual Social
Security Benefit information under Title II of the Social Security Act from the Social Security Administration to an authorized
representative or other individuals without your consent. Sign below to give your consent.
I understand by completing, signing, and dating below, I authorize the Marketplace to disclose to the individuals whose
signatures are provided below as well as any authorized representative
and the appeals authority
any federal tax information in
my eligibility record which was provided by the Internal Revenue Service. I also consent to the release by
GetCoveredNJ
of my
monthly and annual Social Security Benefit information under Title II of the Social Security Act to these same individuals along
with other information in my
GetCoveredNJ
eligibility record, collected based on the application I filled out (or was completed
for me) or that listed me as a household member, and from other data sources like income and employment verification from a
consumer reporting agencythat were used to make the Marketplace eligibility determination.
I understand I can request a copy of my
GetCoveredNJ
eligibility appeal record during the appeals process.
Each adult member of the household must consent to the disclosure of his or her own federal tax information and also consent to
the release of monthly and annual Social Security Benefit information under Title II of the Social Security Act
and other personal
information related to the appeal
by signing below.
The authorization is valid until the resolution of the appeal.
I understand that I must notify Get Covered New Jersey, in writing, if I wish to remove my authorized representative.
I am signing this form under penalty of perjury, which means I have provided true answers to all the questions, and I have
answered to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false
information.
Page 1 of 2
STEP
7
:
Signature (Continued
)
This information applies for all individuals signing below who are 18 or older.
4.
Printed name (First Name, Middle Name, Last Name)
Signature Date (mm/dd/yyyy)
Signatures of any other household members listed on the application for Marketplacecoverage
Even if they’re not included in this appeal, each adult member of the household who is 18 and older must consent to the
disclosure of his or her own federal tax information and also consent to the release of monthly and annual Social Security Benefit
information under Title II of the Social Security Act by signing below.
5.
Printed name (First Name, Middle Name, Last Name)
Signature Date (mm/dd/yyyy)
6.
Printed name (First Name, Middle Name, Last Name)
Signature Date (mm/dd/yyyy)
7.
Printed name (First Name, Middle Name, Last Name)
Signature Date (mm/dd/yyyy)
8.
Printed name (First Name, Middle Name, Last Name)
Signature Date (mm/dd/yyyy)
Page of 2
APL
Optional Form
Appoint an authorized
representative for my appeal
11/2020
Form Approved
Appoint an Authorized
REPRESENTATIVE FOR MY APPEAL
You have the right to choose an authorized representative to help you with an eligibility appeal
. An “Authorized Representative” is a
person/organization you trust to help you with your application or appeal with us, who is able to see your personal information and to act for
you on matters related to this application (including getting information about your application or signing your application on your behalf). If you
would like to assign an Authorized Representative to act on your behalf, complete this page and return it to us. If you ever need to change
your Authorized Representative, contact GetCoveredNJ. If you would like to assign your Authorized Representative over the phone, call us at
1-833-677-1010.
Make a copy for your records and mail the completed form to:
Get Covered New Jersey
Attn: Appeals
PO Box 55898
Trenton, NJ 08638
STEP 1:
Enter information for the person who's requesting an appeal (also called an “appellant”).
STEP 2:
Enter information for the authorized representative.
Authorized representative's first name Middle name
Last name
Mailing address
apartment or suite
number
City
State
ZIP code
Phone number with area code
(
)
Page 3 of 2
STEP 3:
Electronic reminders.
If your authorized representative would like to receive electronic reminders about your appeal, when available, please have them
provide their signature below, as well as the preferred method of correspondence (notifications will not contain personal health
information).
Mobile number
( )
For privacy information, please visit:
getcovered.nj.gov
Email (Remember to check your spam folder)
Email Address
No reminders
Authorized Representative printed name (if choosing to receive electronic reminders) (First name, Middle name, Last name)
Signature
Date Signed(mm/dd/yyyy)
STEP 4:
Signature.
To change or remove your authorized representative, or for more information, contact the Get Covered New Jersey Call Center at 1-
833-677-1010. TTY users can call 711.
If you believe that Get Covered New Jersey has failed to provide these services or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, you can file a grievance with the Get Covered New Jersey by calling the call center (1-833-677-1010) or
by writing to the Get Covered New Jersey Consumer Assistance Center, PO Box 55898, Trenton, NJ 08638. If you need help filing a
grievance, the call center can help you.
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