How do I file a Covered CA Appeal?

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

Appeals Procedure on Covered CA’s Website 

Eligibility Grievance Form Rev 7.2016

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 appeal (click for form)  errors in your application, IF you appoint us (Steve Shorr) as your Certified Insurance Agent, by  following these instructions as we are paid by Covered CA to help you, if you ask them to!

 

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

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

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
 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
 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 income is too low to qualify for Covered California coverage
Other (please provide reason in the space located on the next page)

Navigating the Appeals Process - Patient Advocate Foundation
Navigating the Appeals Process – Patient Advocate Foundation

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