All About Appeals

As a consumer on the Health Insurance Marketplace (, you have the right to appeal decisions that are not in your favor. There are two types of appeals. The first is an appeal of a Marketplace decision (generally a decision on your eligibility to purchase a plan on The second is an appeal of an insurance company’s decision (usually a decision of whether the company will cover a particular drug or surgery).

Appealing a Health Insurance Marketplace ( decision

You have the right to appeal any of the following decisions:

  • Denial of Advanced Payments of the Premium Tax Credit (APTCs) or Cost Sharing Reductions (CSRs)
  • Amount of APTCs or CSRs
  • Adjustment in APTCs or CSRs at end of 90-day inconsistency period
  • Denial of eligibility to enroll in Marketplace coverage
  • Denial of a special enrollment period
  • Termination of Marketplace coverage
  • Denial of coverage exemption
  • Denial of eligibility for Medicaid/CHIP

Important note about eligibility appeals: If the Marketplace says that you are ineligible to buy a plan on, you have 90 days to appeal. Learn more about filing an eligibility appeal here.

Fill out appeal forms online here. If you want a family member or another person to represent you in your appeal, find out how to appoint an authorized representative here. After you have submitted your appeal, you can check on the status of your appeal by calling the Marketplace Appeals Hotline (855-231-1751).

How we can help: A Health Insurance Navigator can help you gather information to file your appeal, and our staff can represent you in your appeal at no cost. 

Appealing a health insurance company decision

If your health insurance company refuses to pay for a procedure or a medication, you have the right to appeal. Your health insurance company is required to let you know why they denied coverage, and they must provide you with information on how to appeal.

There are two types of insurance company appeals: Internal appeals and external reviews.

Internal appeals are reviewed by the health insurance company itself. You can file a request for coverage (also known as a claim) either before or after receiving medical attention. If your health insurance company denies coverage of your claim, you must file your appeal within six months of receiving notice that your claim was denied. Follow the instructions that the insurance company includes with their denial. Click here for more information on internal appeals. 

External reviews are the last option to appeal an insurance company’s denial (outside of the legal system), and they are processed by the North Carolina Department of Insurance. External reviews in NC are free. You can reach the Department of Insurance at 855-408-1212, or you can visit their website to request an external review. Click here for more information on external reviews.

Health Insurance Navigators can help you appeal a health insurance company decision and navigate the appeal process with the NC Department of Insurance. 

To get free help from a Charlotte Center for Legal Advocacy Health Insurance Navigator, call 980-256-3782. You can also book an appointment by visiting

If you or someone you know needs health insurance coverage, a Special Open Enrollment Period is open through Aug. 15, 2021. 

Learn more about how to get covered, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

Charlotte Center For Legal Advocacy Hosts U.S. Department of Health and Human Services Secretary Becerra

Charlotte, NC – Today, the U.S. Department of Health and Human Services Secretary Xavier Becerra and U.S. Rep. Alma Adams visited Charlotte Center For Legal Advocacy and Legal Aid of North Carolina. They conducted a roundtable discussion on local and national health care with representatives of NC Navigator Consortium and other leading figures in the Charlotte community.

The director of NC Navigator Consortium, Mark Van Arnam, answering one of Secretary Becerra’s questions. 

Secretary Becerra and Rep. Adams thanked Charlotte Center For Legal Advocacy and the representatives of NC Navigator Consortium for the results they have achieved getting those in need connected to COVID-19 vaccinations and affordable health care coverage. Secretary Becerra mentioned that President Biden’s new American Families Plan is an important building block of the Affordable Care Act. Secretary Becerra and Rep. Adams made it clear their top priority is increasing vaccination rates and promised to meet the people where they are in order to make it happen.

Secretary Becerra and U.S. Rep Alma Adams taking a tour of Charlotte Center for Legal Advocacy with health insurance navigator Natalie Marles.
Secretary Becerra and U.S. Rep Alma Adams discussing the importance of increasing vaccination rates with the media. 

Anyone in need of health insurance coverage is encouraged to learn more about how to “get covered” on the Charlotte Center For Legal Advocacy website. Due to the COVID-19 Pandemic, the Biden administration has announced a Special Open Enrollment Period that will remain open until August 15, 2021. First-time consumers or individuals who have lost their health coverage can enroll in a plan during this time, and existing consumers can switch plans. NC Navigator Consortium Health Insurance Navigators are standing by to help.

Charlotte Center For Legal Advocacy can provide those in need with information, advice and advocacy in consumer protection, home preservation, health care access and public benefits, immigration, tax assistance and more. Our mission is to pursue justice for those in need. Our vision is to build a just community, where all people are treated fairly and have access to legal representation to meet their basic human needs of safety, economic security and stability.

New Subsidies Available For Those Approved For Unemployment

Starting July 1, 2021, individuals may be eligible for additional savings and lower costs on their 2021 (Health Insurance Marketplace) plan if they received, or were determined eligible to receive, unemployment compensation in 2021.  

What does this mean for you?  

If you or your spouse received unemployment income for at least one week in 2021, your whole household may be eligible for a higher tax credit that may cover your monthly premium in full, regardless of your household’s income. In addition, you may be eligible for higher cost-sharing reductions to lower your deductible, copays and out of pocket costs if you select, or currently have, a Silver plan on (See the difference between Bronze, Silver, Gold and Platinum plans in our Basic Health Insurance Terms blog post.)

What do I need to do?  

If you are currently enrolled in a plan, and you or your spouse received at least one week of unemployment compensation in 2021, you must report a change on your application and add unemployment compensation as part of your income. Even if you already reported that you received (or are receiving) unemployment, you will need to update your application to get these enhanced benefits. You can reselect your current plan or change plans if you want to.  

If you are not enrolled in a plan, you can apply to see if you qualify for these enhanced subsidies under the Special Open Enrollment Period open now through Aug. 15, 2021. (If you complete an application and select a plan before July 31, 2021, your plan will start on Aug. 1, 2021.) See the Get Covered section of our website to learn more and book an appointment with a Health Insurance Navigator.  

If I only received one week of unemployment and I have no income now, would I still qualify?  

Yes! You may be eligible to receive enhanced benefits even if you have no income at the moment and your unemployment compensation already expired.  

Learn more about how to get covered on, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

What Is Included in Every Plan?

All plans are required to cover preventive health services 100%. Additionally, these plans are required to include 10 types of health services—called Essential Health Benefits. Keep reading to learn more about these services below.

If you need health insurance coverage through, a Special Open Enrollment Period is now open through Aug. 15, 2021.

Preventive Health Services

Preventive health services are routine health care procedures, like screenings, check-ups and counseling to prevent illness, disease and other health problems.

This means that insurance companies cannot charge you a copay or coinsurance to get this type of medical attention. For example, immunizations, children’s vision screenings, contraception and well-woman visits are free. Get specific lists of preventive services for adults, women and children.

Preventive services are free only when you get them from a doctor or other provider in your plan’s network. (A network is the facilities, providers and suppliers your health insurance company has contracted with to provide health care services.) Talk to your doctor about taking advantage of these free services to keep you and your family healthy. 

Essential Health Benefits

While most of these services won’t be free, plans will pay for at least a portion of the costs of these services.

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services, as well as chronic disease management
  • Children’s oral and vision care

Learn more here: 

Learn more about how to get covered on, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

Mental Health and the ACA plans are required to help pay for mental health services like counseling and psychotherapy. plans can’t put yearly or lifetime dollar limits on coverage of mental health services.

Additionally, some mental health services are completely free. For example, alcohol abuse screening and counseling, as well as depression screening, are free for adults. And behavioral health assessments are free for children at no cost. You can find more free preventive services for adults and children on

To find out how much of the cost of mental health services is covered by your health insurance plan, look at the Summary of Benefits and Coverage. This document is available in your account, or you can call your health insurance company to get a copy. When you’re shopping for a health insurance plan and know that you will want to use mental health services, make sure you compare the Summary of Benefits and Coverage documents of each plan.

To find a therapist or other mental health professional in the Charlotte area, you can use the Bright Health provider search tool or the Blue Cross Blue Shield provider search tool (tip: search “psychology” or “psychiatry”).

If you need health insurance coverage, a Special Open Enrollment Period is open through Aug. 15, 2021. 

Learn more about how to get covered, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

National Suicide Prevention Hotline: 1-800-273-8255

Basic Health Insurance Terms

There are a lot of special terms in the health insurance world, and they can be difficult to understand. We’re here to help you make sense of terms you see on

If you need health insurance coverage, a Special Open Enrollment Period is open through Aug. 15, 2021.

Learn more about how to get covered, or call 980-256-3782 to reach a Health Insurance Navigator for free assistance. You can leave a message with a quick question or schedule a longer phone appointment.

Catastrophic Health Plan
The premium amount you pay each month for healthcare is generally lower than for other plans, but the out-of-pocket costs for deductibles, copayments and coinsurance (see terms defined below) are generally higher. To qualify for a Catastrophic plan, you must be under 30 years old OR get an “affordability exemption” (the Marketplace determines that you’re unable to afford health coverage).

A federal law that may allow you to temporarily keep health coverage after your employment ends. If you choose COBRA coverage, you pay 100% of the premiums, including the portion that your employer used to pay, plus a small administrative fee.

Like a copayment (see next term), but in the form of a percentage of the cost of a healthcare service (e.g. you pay 20% of the cost of a visit or procedure).

A set amount that you pay for a medical service or item, like a doctor’s visit. The insurance company covers the rest.

The amount you have to pay for covered health care services (e.g. doctor and hospital visits, labs, etc.) before your health insurance or plan begins to pay. Often, the health insurance company will only pay a percentage of the costs after you reach your deductible. If you think you will need a lot of healthcare services in a year, you should look for plans with a low deductible.

Metal Categories of Health Plans
In addition to catastrophic plans, plans come in four metal categories: Bronze, Silver, Gold and Platinum. Bronze plans are usually best for individuals who have few health needs but want to be prepared in case of an emergency. Bronze plans have the lowest monthly premiums, but they have a high deductible. Gold and Platinum plans are often best for people who use a lot of health services. They have the highest monthly premiums, but each visit to the doctor and each prescription will have a low copay/coinsurance. Plans in all metal categories provide free preventive care (for example, a yearly wellness visit to your doctor).

Silver plans are ideal for individuals/families with income less than 250% FPL. If you select a Silver plan, you will receive cost sharing reductions, which means your out of pocket costs (deductible, coinsurance and copays) are also subsidized and may be very low.

The doctors, hospitals and suppliers your health insurer has contracted with to deliver health care services to their members. Ask a healthcare provider if they accept your insurance before you visit. If you go out of network, your care will be more expensive.

Out-of-pocket Maximum
Usually a larger number than your deductible. This is the absolute maximum amount of money you will have to spend in the year on healthcare costs. After you reach this amount, the health insurance company will cover all services 100%.

Plans and Prices Tool 
Saves you time! This tool allows you to see what plans are available in your area and how much financial assistance you qualify for before you fill out an application. 

Pre-existing Conditions
A health problem, like asthma, diabetes, or cancer, that you had before the date that new health coverage starts. Insurance companies can’t refuse to cover treatment for your pre-existing condition or charge you more.

The amount you pay for your plan each month.

Premium Tax Credit
The “subsidies” that lower the cost of your monthly premiums. You can take the premium tax credits in advance to lower your monthly cost, or you can take them as a refund at tax time. See this blog post for more on how Premium Tax Credits can impact your 2020 taxes.

To look up more key terms, visit the glossary. Premium Tax Credits and Filing Your 2020 Taxes

FYI, this blog post is most appropriate for those who accessed health insurance coverage through in 2020. If you started your coverage in 2021, this information does not apply.

If you currently do not have health insurance, we can help! Click here to learn more and make an appointment with a health insurance navigator today.

The reason health insurance on is so affordable for many people is because the government subsidizes your monthly premiums based on your income. These subsidies are also called Premium Tax Credits, and, if you receive them each month during the year, they are called Advance Payments of the Premium Tax Credit (APTCs). 

If you receive government subsidies, you need to reconcile these payments on your taxes each year. The IRS requires you to do this to make sure that you received the proper amount of subsidies based on your income.

Usually, if your income at the end of the year is higher than you estimated on your application, you will need to pay back some of your subsidies. This is because you were given more subsidies than people with your income level should qualify for. When you file your taxes, you use Form 8962 to see how much premium tax credit you qualify for based on your actual year-end income. Then, you see how much APTC you actually received. If the amount you qualify for on Form 8962 is less than the amount you actually received during the year, then you need to repay the excess amount to the IRS.

How do I know if I received APTCs?

If you enrolled yourself or a family member in a plan, you will receive Form 1095-A from the Health Insurance Marketplace. This form will show the months that you have been covered by a plan and will show the amount of APTC that you was paid to your health insurance company on your behalf. The Marketplace also provides this information to the IRS.

What is the change for filing 2020 taxes? What do I need to do?

This year the IRS announced that you do not have to report excess APTCs when you file your 2020 taxes. So, when you are doing your calculations on Form 8962 and you discover that you received more subsidies than you actually ended up qualifying for, you do not need to pay back that excess amount this year. You do not need to report excess subsidies on your taxes for 2020.

If you find on Form 8962 that you actually received a smaller amount of subsidies than you qualify for based on your year-end income, you should definitely file form 8962 so you can get a tax refund.

What if I already filed my taxes?

If you already filed your taxes for 2020 and had to repay excess APTC, you do not need to file an amended tax return or contact the IRS. The IRS will reimburse you automatically. 

As a reminder, this change applies only to tax year 2020. The deadline to file your 2020 taxes is Monday, May 17, 2021.

Want to know more? Click here to read the IRS’ official announcement and fact sheet.

What does the American Rescue Plan (third stimulus package) mean for the Affordable Care Act?

What you need to know about the Special Open Enrollment Period: 

1. Anyone can sign up for a plan now.  

It’s easy to sign up for health insurance if you recently lost your job or are self-employed. Even if you haven’t had insurance in a long time, this Special Open Enrollment Period may be for you!  

This is just like the annual Open Enrollment Period that happens in November and December. This Open Enrollment Period is open through August 15. If you enroll, your plan will start the first day of the following month. For more or to make an appointment with a Health Insurance Navigator, visit

2. You can change your plan if you want, but you will probably have to re-start your deductible. 

Through August 15, current enrollees can change to a new plan that will last for the rest of the year. But you should consider how much you’ve already paid toward your deductible and/or other out of pocket expenses when deciding whether or not to change your plan.  When you change plans, the amount you’ve paid already towards meeting your prior plan’s deductible and/or out pocket expenses may be reset to zero, and you would need to start over paying out of pocket expenses to reach the deductible on your new plan.  If you have made significant payments toward your deductible, check with your insurance company to see how it might impact you and what options are available to keep credit toward what you have already paid. 

What people need to know about the relief bill and its changes to the ACA: 

1. Lower monthly premiums: federal government subsidies will reduce the amount you have to pay for health insurance each month. 

The plan significantly increases premium tax credits for 2021 and 2022. These increased subsidies will substantially reduce or even eliminate monthly premiums for millions of people with Marketplace plans.  

On average, premiums will decrease by $50 per month. No one will have to spend more than 8.5% of their income on premiums. People with income below 150% of the poverty line (about $19,000 for a single person, $25,800 for a couple, and $39,000 for a family of four) will pay no premiums for some plans, including Silver plans with cost sharing reductions. 

Current enrollees, including those who recently enrolled through the 2021 Special Enrollment Period, will need to update their applications to get the new subsidies. These subsidies will be visible on starting April 1, and you will start receiving them on May 1. You will need to reselect your current plan for the changes to take effect to reduce your premiums for the remainder of the year. If you do nothing, you do not lose access to the tax credits, but you’ll get them as a refund when you file your taxes next year. When you file your taxes in 2022, you will get a reimbursement of the additional tax credits you would have qualified for from January through April 2021.  

Due to the SOEP, you may be able to change plans until August 15. If you qualify for these additional benefits, the new tax credits will be applied to your policy starting on May 1.  

If you purchase a plan now, you will get a refund if you go back into your application after April 1. 

2. Increase Subsidies for Those Who Have Lost Their Jobs 

The plan expands premium tax credits for people who receive unemployment benefits in 2021. This means that individuals currently unemployed are guaranteed to get the most generous subsidies on It doesn’t matter what their actual year-end income is.  

These additional tax credits will be available starting this summer. 

3Protect Families from Having to Pay Back Subsidies 

In 2020 some people lost their jobs early in the year but later got new ones with higher earnings than they had expected. Others worked additional hours or received bonus pay as essential workers. The American Rescue Plan exempts low- and moderate-income families from having to repay the premium tax credit they received in 2020.  

4. Government will pay the cost of COBRA coverage 

If you lost your job and your job’s health insurance, you can use COBRA to keep your same health insurance plan. But instead of losing your employer’s contribution for your premiums, the government will pick up the bill. The government will pay the entire COBRA premium from April 1 through September 30, 2021. 

If you get a new job that offers health insurance before Sept. 30, you will lose eligibility for this no-cost COBRA coverage. And someone who left a job voluntarily would not be eligible, either. 

We encourage you to review your options with the Marketplace before signing up for COBRA, since plan options may be more attractive to you, depending on your particular situation.  


The Open Enrollment Period is often the only opportunity for individuals and families to sign up for a health insurance plan for the following year. Until August 15, 2021, you can sign up for a 2021 plan.

Charlotte Center for Legal Advocacy’s health insurance navigators help families and individuals choose plans that are best for them within the Health Insurance Marketplace implemented under the Affordable Care Act (ACA). During this Open Enrollment Period, navigators have received calls and questions from Cabarrus, Mecklenburg and Union County residents about the household income section of the application. With this year’s pandemic and economic uncertainty, many have lost or changed employment and are struggling to estimate their income.

Listed below are some helpful tips and general guidelines. More of what to (and not to) include is available at

Important points:

  • You must estimate your projected income for 2021.
    • If you are unemployed, it may be difficult to do this. Estimate how much you would make if you returned to your previous job.
    • If you don’t have a set salary or wages (for example, if you are a freelance worker, seasonal worker, or run your own business), it will be easier to estimate your income if you have a copy of your tax return from last year on hand.
    • If you are self-employed, you should input your net income. Click here for more help estimating your self-employment income.
    • If your income is very low or if you are unemployed, and you or a family member falls into one of the following groups, you may qualify to receive Medicaid: children under 21, pregnant women, women with breast or cervical cancer, individuals age 65 or older, blind or disabled individuals, people in need of long-term care, or people receiving Medicare.
  • You must report changes in income.
    • During the year, you must go back into your application to report if your income goes up or down. This will keep your monthly premium at a manageable price and help to reduce the amount of financial assistance you may have to pay back, if any at all.
  • You can receive financial assistance.
    • Estimating your income as accurately as possible allows the Marketplace to determine your eligibility for financial assistance.

Be sure to include:

  • Anticipated changes in income
    • Consider these questions: How might your income change in the coming year? Are you expecting business to improve or worsen? Will you be getting a raise? Work more hours? Get a seasonal job? Will another household member get a job? Will you gain or lose a dependent?
  • The anticipated income of all household members
    • If another person in your tax household has health coverage through a different plan or program, you still need to include their income on your application. Marketplace financial assistance is based on the income of all tax household members. You will be able to clarify on the application which household members do not need health coverage. Tax household members not applying for coverage are not required to provide any other information except income information (e.g. They do not have to provide a Social Security Number).
  • Some disability-related income
    • Only include Social Security disability payments when estimating your income for next year. Do not include Supplemental Security Income, only Social Security retirement or disability payments.
  • Income from investments
    • Things like stocks and bonds.
  • Alimony
    • Include only if your divorce or separation was finalized before January 1, 2019.

Do NOT include:

  • Self-employment expenses
    • Subtract any self-employment expenses from your estimated income.
  • Some disability-related income
    • Do not include Veterans’ disability income payments, Supplemental Security Income (SSI) payments, and workers’ compensation payments when estimating your income for next year.
  • Social Security payments for applications that have not yet be approved
    • You can update your Marketplace application later next year if your application is approved.
  • Alimony
    • Do not include if your divorce or separation was finalized on or after January 1, 2019.
  • Child support

Free appointments with a local navigator can be made using the statewide appointment hotline at 1-855-733-3711, or online at Appointments are filling quickly! Open Enrollment to sign up for a health insurance policy for 2021 will end August 15, 2021!

More Resources:

More information on how to report your income:

And on what to include:


Woman holds child while talking on the phone and taking notes

Charlotte Center for Legal Advocacy’s health insurance navigators help families and individuals choose plans that are best for them within the Health Insurance Marketplace implemented under the Affordable Care Act (ACA). During the Open Enrollment Period, navigators take appointments free of charge with residents of Cabarrus, Mecklenburg and Union County who are concerned about making common errors that could jeopardize their ability to maximize coverage and minimize cost. 

Find FAQs and how to make an appointment and keep reading to learn the top four mistakes navigators see people make on the Health Insurance Marketplace.

1. Missing the Deadline 

The Open Enrollment Period is going on now through August 15, 2021. It is very difficult to qualify to sign up for health insurance on the Marketplace beyond the designated timeframe. Usually, adjustments or new enrollments are allowed only as a result of a major life event, such as marriage, divorce, job loss or a new child. 

2. Misunderstanding Costs 

During Open Enrollment, some people only look at the cost of premiums and don’t take into consideration the deductibles, copays, coinsurance and out-of-pocket maximums. These are all important factors that will help determine your overall health care costs in 2021. 

3. Over- or Under-Insuring 

A basic high-deductible plan generally has the lowest monthly premium, but it requires the policy holder to spend more before full coverage kicks in. Some people mistakenly select this option because they think it will be cheapest, but they ultimately pay more out of pocket. Navigators suggest a quick assessment of your health care spending over the last couple of years. If you tend to undershoot your deductible, you might be better off moving to a high-deductible plan. If you usually hit your deductible before it resets, you could come out ahead by paying a higher premium for a heartier plan. Remember: The cost of many preventive measures, such as mammograms, colonoscopies and cholesterol screenings, are covered 100% before you meet your deductible and require no copay.  

4. Opting Out

A few years ago, not buying health insurance meant facing a potentially costly penalty. While that penalty no longer exists, forgoing coverage is a big mistake. A single illness or injury could total thousands of dollars out of pocket.

Still looking for the answer to your question or need additional guidance to get signed up on the Health Insurance Marketplace? Make an appointment with a navigator and sign up for additional information today.