Is there more than one basis for an administrative appeal?
Pursuant to 45 CFR 156.1220, an issuer may file an administrative appeal to contest a processing error by HHS, HHS’s incorrect application of the relevant methodology, or HHS’s mathematical error only with respect to:
When must an issuer submit a request for reconsideration (that is, the first level of an administrative appeal)?
|Reconsideration Request Type||Deadlines|
|For advance payments of the premium tax credit, advance payments of cost-sharing reductions, Federally-facilitated Exchange user fee charges, or State-based Exchanges utilizing the Federal platform fees||Within 60 calendar days after the date of the final reconsideration notification specifying the aggregate amount of advance payments of the premium tax credit, advance payments of cost-sharing reductions, Federally-facilitated Exchange user fees, and State-based Exchanges utilizing the Federal platform fees for the applicable benefit year|
|For reconciliation of the cost-sharing reduction portion of advance payments||Within 60 calendar days of the date of the cost-sharing reduction reconciliation discrepancy resolution decision; and|
|For a risk adjustment payment or charge, including an assessment of risk adjustment user fees, the findings of a second validation audit, or the calculation of a risk score error rate as a result of risk adjustment data validation||Within 30 calendar days of the date of the notification provided by HHS under 45 CFR 153.310(e).|
|For a default risk adjustment charge||Within 30 calendar days of the date of the notification of the default risk adjustment charge.|
|For a reinsurance payment||Within 30 calendar days of the date of the notification provided by HHS under 45 CFR 153.240(b)(1)(ii)|
|For a risk corridors payment or charge||Within 30 calendar days of the date of the notification provided by HHS under 45 CFR 153.510(d).|
How can an issuer make a request for reconsideration for the risk adjustment, reinsurance, risk corridors or cost-sharing reduction reconciliation programs?
For the 2017 benefit year, you can access the Risk Adjustment (including risk adjustment default charge and risk adjustment user fees), and Cost-sharing Reduction Reconciliation Reconsideration Request Web Forms at: https://acapaymentoperations.secure.force.com/ACAReconsideration. Please note the program-specific Reconsideration Request Web Forms will only be available during the applicable regulatory administrative appeals window.
What if an issuer’s request for reconsideration is unsuccessful?
A reconsideration decision is final and binding for decisions regarding the advance payments of the premium tax credit, advance cost-sharing reduction payments, or Federally-facilitated Marketplace user fees.
A reconsideration decision with respect to other matters is subject to the outcome of a request for informal hearing filed in accordance with 45 CFR 156.1220(b).
For Further Questions:
Issuers with additional questions can email the Administrative Appeals Mailbox, ACAfinancialappeals@cms.hhs.gov.