1614.8 Federally Facilitated Exchange (FFE) Fair Hearing

An applicant may appeal a decision made by the Federally Facilitated Exchange (FFE) concerning his/her application for coverage and/or eligibility for the subsidy through the Health Insurance Marketplace. That appeal request will be sent to the Marketplace Appeals Center for adjudication. During the appeal process the Marketplace Appeals Center may determine that the appellant is potentially eligible for Medicaid or CHIP coverage.

In that instance, the Marketplace Appeals Center will submit an electronic appeal package to the agency containing consumer account information. The package of information will include not only information provided directly by the applicant when he/she completed the Health Insurance Marketplace application, but also data obtained from the result of any verifications performed by the Federally Facilitated Exchange (FFE). Also included in the package is the appeal request submitted by the appellant. This information shall be used by the agency to review the individual’s eligibility for medical assistance.

NOTE : The agency should only receive an appeal package for individuals who have already applied for and been denied Medicaid and/or CHIP coverage by the agency.

Upon receipt of the appeal package, the agency shall conduct an administrative review of the case based on the information provided and redetermine eligibility for Medicaid and/or CHIP coverage. If the applicant is determined eligible based on the review, coverage shall be promptly approved with notification provided to the applicant. If the agency determines that the applicant is not eligible, the application shall remain denied. The applicant shall be notified of the decision with the right to appeal. Whatever decision is made, the agency shall also notify the FFE of the outcome of the redetermination.