How do I file a Covered CA Appeal?
Right to Appeal - if claim denied
FAQ's - Ask us a Question
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.
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!
§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)
- June 22, 2011 CMS-9993-IFC2: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes – Opens in a new window
- July 26, 2011 CMS-9993-CN: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction – Opens in a new window (PDF – 184 KB)
Article 7. Appeals Process for the Individual Exchange
- § 6602. General Eligibility Appeals Requirements.
- § 6604. Notice of Appeal Procedures.
- § 6606. Appeal Requests.
- § 6608. Eligibility Pending Appeal.
- § 6610. Dismissals.
- § 6612. Informal Resolution.
- § 6614. Hearing Requirements.
- § 6616. Expedited Appeals.
- § 6618. Appeal Decisions.
- § 6620. Appeal Record.
- § 6622. Employer Appeals Process.
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!
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.
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)