The Affordable Care Act Financial Administrative Appeals Process for Issuers
In 45 CFR 156.1220, HHS established an administrative appeals process applicable to the financial management programs set forth in the Affordable Care Act – risk adjustment, reinsurance, risk corridors, advance payment of the premium tax credit (APTC), cost-sharing reductions (CSRs), including reconciliation of the CSR portion of advance payments (CSR reconciliation) and Federally-facilitated Exchange (FFE) user fees. The administrative appeals process generally consists of:
- Request for Reconsideration;
- Informal Hearing before the CMS Hearing Officer; and
- Review by CMS Administrator (at the discretion of the CMS Administrator).
A reconsideration decision is final and binding for decisions regarding the APTC, advance CSR payments, or FFE user fees. For risk adjustment, reinsurance, risk corridors, and CSR reconciliation administrative appeals, the final agency decision may be the reconsideration decision if the issuer does not request an informal hearing before the CMS Hearing Officer or the informal hearing before the CMS Hearing Officer decision if no party requests CMS Administrator review or the Administrator declines review.
ACA Request for Reconsideration web page to locate Request for Reconsideration web forms: https://acapaymentoperations.secure.force.com/ACAReconsideration/
Further information regarding the Administrative Appeals process is located in the Common Administrative Appeals Questions section of this webpage.
For Further Questions:
Issuers with additional questions can email the Administrative Appeals Mailbox, ACAfinancialappeals@cms.hhs.gov.
- Regulations & Guidance
- Information related to the Discrepancy Reporting Process
- Educational Materials for the Administrative Appeals Process
- PPACA Financial Appeals Risk Adjustment (including Risk Adjustment Default Charge and Risk Adjustment User Fee, and High-Cost Risk Pool) Reconsideration Request Web Form Guide - 2018 Benefit Year (PDF)
- Other Resources
- March 5, 2020 Information Related to COVID–19 Individual and Small Group Market Insurance Coverage
- March 12, 2020 FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19)
- March 18, 2020 FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in Response to Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency
- March 24, 2020 FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets
- April 11, 2020 FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation
*This document was updated on April 15, 2020, to correct an error in footnote 10 regarding the current end date of the public health emergency related to COVID 19.
- April 13, 2020 Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation (HHS-RADV)