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The Center for Consumer Information & Insurance Oversight

 

Common Administrative Appeals Questions

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:

  • The amount of advance payments of the premium tax credit, advance cost-sharing reduction payments, or Federally-facilitated Marketplace user fee charges for a benefit year;
  • The amount of a reconciliation payment or charge for cost-sharing reductions for a benefit year;
  • The amount of a risk adjustment payment or charge for a benefit year, including an assessment of risk adjustment user fees;
  • The amount of a risk adjustment default charge for a benefit year;
  • The amount of a reinsurance payment for a benefit year;
  • The amount of a risk corridors payment or charge for a benefit year;
  • The findings of a second validation audit as a result of risk adjustment data validation with respect to risk adjustment data for the 2016 benefit year and beyond; or
  • The calculation of a risk score error rate as a result of risk adjustment data validation with respect to risk adjustment data for the 2016 benefit year and beyond.

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.