How do I file a Covered CA Appeal?

We are not attorneys and can just point out the law, rules, relevant sections in the EOC Evidence of Coverage.

Check out the forms and Appeals Procedure on Covered CA’s Website , the materials below and to the right, our main page on Appeal & Grievances?  and the child & sibling pages.

We also need you to write out your story and including all the proofs – evidence & exhibits.

See also our main page on appeals, namely how to gather your evidence and exhibits.   Here’s an example of a decision from the Administrative Law Judge for Covered CA.

We might be able to help you file and process your  appeal  (click for form)  , IF you appoint us (Steve Shorr) as your Certified Insurance Agent, by  following these instructions as we are paid a measly monthly sum  by Covered CA to help you.

Reasons for filing a Covered CA appeal

Your eligibility notice explains what you are eligible for and the programs for which you do not qualify. Depending on your eligibility results, you may appeal any of the following (check as many boxes as you would like):

 I was denied enrollment into a Covered California health plan
 The amount of Premium Assistance (tax credits that help pay my monthly premium) is not correct – Get Calculation
 The level of Cost Sharing Reduction (help paying my out of pocket expenses) is not correct
 I was denied eligibility for an exemption from the individual responsibility CA Mandate Penalty
 Covered California did not process my information in a timely manner
 Covered California stated that I am not a US Citizen or US National or a lawfully present individual living in the United States
 Covered California stated that my application was incomplete
 I do not have other health coverage (such as free Medi-Cal or employer sponsored insurance) that prevents me from qualifying for insurance through Covered California
 Covered California stated that I am not a California Resident
 Covered California stated that I did not pay my premiums by my due date
 Covered California stated that my MAGI income is too low chart to qualify for Covered California coverage  Get Calculation
Other Tell us more about why you disagree with Covered California’s decision. You may attach additional sheets of paper if you need more space to write.   We STRONGLY suggest you do.  Be sure to read all the helpful aids we have on this page.  You are going up against well versed opponents!

 

For other appeals check our Site Map, Child & Related Pages below.

Sample Letter for Appeal 

Sample Letter for Covered CA Appeal
 

Covered CA Appeals Decision

Covered CA Appeals Decision

Explanation on Insure Me Kevin . com   Polk Case

Get Instant Individual & Family Quotes including Subsidy Calculation
Get Instant Individual & Family Quotes including Subsidy Calculation

Open Enrollment till January 31st

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Extensive Video explanation of how to use all features of our quote engine

 

Historical

Their service is the worst I have seen since earning my Degree in Insurance at San Diego State University in 1975.  I learned the word SNAFU from a guy I knew in the Dorm.  This is the first time, I’ve been able to use the word in “real” life.   Please note how many of the 8,000 certified agents are now refusing to deal with Covered CA.  See screen shots below from Ehealth Insurance and another agent.  It’s twice the work, for less than 1/2 of what we were paid last year and “criminal” support and customer service!

However, if you qualify for Medi-Cal we do not get compensated and it appears we are supposed to refer you to your local County Medi Cal Agency.

Hurry, we may well soon be FORCED to charge a fee for appeals and consultation for Covered CA.

1.29.2015 Update – Through the Covered CA Agent Portal & Email, I’m now getting pretty good service & response.

fluker
One of our friendly competitors is leaving the market

 ehealht

Appeals Law

Subpart F—Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs

§155.500   Definitions.

§155.505   General eligibility appeals requirements.

§155.510   Appeals coordination.

§155.515   Notice of appeal procedures.

§155.520   Appeal requests.

§155.525   Eligibility pending appeal.

§155.530   Dismissals.

§155.535   Informal resolution and hearing requirements.

§155.540   Expedited appeals.

§155.545   Appeal decisions.

§155.550   Appeal record.

§155.555   Employer appeals process.

July 23, 2010 OCIIO-9993-IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act – Opens in a new window (PDF – 257 KB)

CA CCR

Article 7. Appeals Process for the Individual Exchange

5 comments on “Covered CA Appeals

  1. I made a mistake and took my child off the coverage as she was out of state to go to college. She’s in the ER, what can I do?

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