The APTC denial notice arrives and the client calls you. Sometimes the income figures are simply wrong. Sometimes the Marketplace's data-matching pulled the right number from the wrong year. Whatever the cause, the 90-day window started running the day the notice was issued, not the day anyone read it.
Key Takeaways
- The appeal window is 90 days from the eligibility determination notice, not from enrollment.
- Interim APTC can continue during an appeal under 45 CFR 155.520 if the client requests it in writing.
- Two appeal tiers exist: internal Marketplace review first, then external independent review if unresolved.
- Income verification failures are the most common trigger; a signed 1040 or IRS transcript usually resolves them.
- Brokers need written client authorization before initiating or participating in an appeal.
Marketplace eligibility appeals are governed by through 155.545. The regulatory framework gives clients a two-tier process: an internal Marketplace review, then an external independent review if the internal review does not resolve the issue. Brokers who understand both tiers move faster than those who treat every appeal as a Healthcare.gov call center situation. Inshura, for example, does not advertise a structured appeals workflow for brokers on its public site as of July 2026; this is an area where a documented internal process adds real value to an agency's service offering.
The two-tier appeals structure
The internal review is the first stop. For Healthcare.gov (FFM) states, the appeal goes to CMS's appeals unit. For state-based exchanges (SBEs), it routes to the state agency's designated appeals body. The internal review must produce a written decision within 90 days of receiving the complete appeal request.
If the internal review confirms the original eligibility determination, the client has 30 days to request an external independent review. For FFM states, this goes to MAXIMUS Federal Services, the third-party entity under CMS contract for independent appeals. The external review is binding on the Marketplace. The Marketplace cannot simply re-deny a determination that the external reviewer overturns.
| Phase | Timeframe | Handled by | Outcome |
|---|---|---|---|
| Request for reconsideration (internal) | Must file within 90 days of eligibility notice | Marketplace appeals unit (Healthcare.gov or SBE) | Written decision within 90 days of receiving complete appeal request |
| External appeals review | Request within 30 days of internal denial | Independent appeals entity under CMS contract (MAXIMUS Federal Services for FFM) | Written decision typically within 90 days; binding on the Marketplace |
| Interim APTC continuation | Must request at time of or before submitting appeal | Marketplace processes; client continues receiving APTC | APTC continues at challenged amount during review; excess may be reconciled on 8962 if appeal denied |
Timelines from 45 CFR 155.505 to 155.545. State-based exchange timelines may vary by state rule. Confirm with the relevant SBE for non-FFM states.
Interim APTC continuation: protecting coverage while you wait
Under , a client can request that APTC continue at the challenged amount while the appeal is pending. The request must be made at the time of the appeal or before. It does not happen automatically.
The practical consequence: if the Marketplace denied APTC or reduced it, the client can keep the pre-denial APTC amount flowing through the appeal period rather than paying full premium while waiting for the review. The catch is reconciliation. If the appeal is ultimately denied, the IRS reconciles the excess APTC on at the end of the tax year. The client owes the difference. For a client whose appeal is borderline, this is a meaningful financial risk to walk through before requesting continuation.
The reconciliation cap provides some protection. The repayment cap for household incomes between 200 and 400 percent FPL ranges from $375 to $1,650 per person (2025 values). Above 400 percent FPL, the full excess is owed. Clients near the top of the subsidy range who request continuation on a long-shot appeal can face material reconciliation bills.
Five common denial triggers and their documentation
Most eligibility denials fall into a handful of categories. Each has a primary documentation path that resolves the majority of cases at the internal review stage.
| Denial trigger | Common cause | Primary document | Typical resolution |
|---|---|---|---|
| Income verification failure | MAGI on application does not match IRS records within 10 percent tolerance | Signed IRS Form 1040 or IRS Tax Return Transcript (4506-C) | Usually internal review; 60 to 90 days |
| Citizenship or immigration status | SAVE system match failure on immigration status; naturalization records not yet updated | Naturalization certificate, U.S. passport, or I-551 permanent resident card | SAVE re-query; can take 30 to 45 days beyond internal review |
| Employer coverage affordability denial | Marketplace determined employer offer is affordable using household income test | Employer's Section 125 plan documents; written employer statement of plan cost | Internal review; may need external if employer disputes |
| SEP eligibility denial | Marketplace could not verify triggering life event (loss of coverage, move, etc.) | COBRA election notice, employer termination letter, or landlord lease for new address | Usually internal review; 30 to 60 days |
| Medicaid or CHIP determination redirect | State Medicaid agency determined eligibility, but client disputes or prefers Marketplace | State Medicaid denial notice; client income documentation | Coordination between state Medicaid and Marketplace; timeline varies by state |
Documentation requirements can vary by Marketplace and by state. Confirm the specific documents requested in the eligibility notice before submitting. Timelines are approximate.
The income verification case in detail
Income verification failures account for the majority of APTC appeals. The Marketplace data-matches application MAGI against IRS records through the Federal Data Services Hub. If the match is within 10 percent, the application is accepted. Beyond that threshold, the Marketplace flags the discrepancy and may reduce or deny APTC.
Two scenarios cover most cases. First, the client's income genuinely changed year over year and the IRS records reflect the prior year's higher income. The fix is projecting current-year income correctly on the application and submitting the most recent W-2 or 1099 to document the change. Second, the data match pulled a different tax year than intended. The 4506-C transcript request, or a signed 1040, clarifies which year's income is operative.
Self-employed clients are the hardest income verification cases because their reported income varies and IRS records often lag. A detailed profit and loss statement, bank statements covering the year-to-date period, and prior year Schedule C filed with the 1040 together build the strongest income documentation package for a self-employed APTC appeal.
What brokers need before starting an appeal
A written appointment of representative (AOR) from the client is required before a broker can act in an appeal. The Healthcare.gov appeal form includes an authorized representative section. SBEs have their own forms. Without written authorization, the Marketplace will not share appeal correspondence with the broker or accept documents submitted on the client's behalf.
Verbal authorization is not sufficient. Agencies that handle appeals regularly keep a standard written AOR on file, signed at enrollment, that covers eligibility-related communications. This removes the step of chasing a signature when a denial notice arrives.
Three other preparation steps that save time once the appeal is filed:
Get the notice date in writing. The 90-day window runs from the notice date. Ask the client to forward or photograph the actual eligibility notice. The call-center representative's verbal statement of the date is not a reliable record for a deadline this important.
Assemble documentation before contacting the Marketplace. Internal review decisions come within 90 days of a complete appeal request. Submitting an incomplete appeal and then sending documents piecemeal restarts the clock on what counts as a "complete" submission in practice, even if not legally.
Track every contact with date, time, and representative name. Appeals that reach the external review stage benefit from a documented interaction log showing that the broker made reasonable efforts to resolve at the internal level. It also protects the agency if the client later disputes the timeline.
State-based exchange differences
The 45 CFR regulatory framework applies to FFM (Healthcare.gov) states. State-based exchanges have their own appeals procedures that must meet federal minimum standards but may differ in form, timeline, or documentation requirements. California's Covered California, New York's NY State of Health, and Colorado's Connect for Health all run their own appeals bodies.
The 90-day window and the two-tier structure are federal minimums; some SBEs are more generous. A broker operating across multiple SBE states should maintain a short reference card with each exchange's appeals contact, form location, and any state-specific documentation requirements. Assuming the Healthcare.gov appeal process maps exactly to Covered California's will produce avoidable errors.
Frequently asked questions
FAQ
How long does a client have to appeal a Marketplace eligibility decision?
90 days from the date on the eligibility determination notice under 45 CFR 155.505. The clock starts on the notice date, not the date the client reads the notice or calls you. Missing the 90-day window forecloses the formal appeal process, though some states allow hardship exceptions for good cause. File early; there is no advantage in waiting.
Can a client receive APTC while an appeal is pending?
Yes, under 45 CFR 155.520. The client must affirmatively request interim benefit continuation when filing or before filing the appeal. The Marketplace will continue APTC at the challenged amount. If the appeal is ultimately denied, the client may owe back the excess APTC on Form 8962 at tax time. Clients should understand this reconciliation risk before requesting continuation.
What is the difference between the internal Marketplace review and the external appeal?
The internal review is handled by the Marketplace's own appeals unit. For Healthcare.gov (FFM states), this is within CMS. For state-based exchanges, it's the state agency. If the internal review confirms the original decision, the client can request an external independent review from a third-party appeals entity under CMS contract. The external review is binding on the Marketplace. Most income verification cases resolve at the internal stage with the right documentation.
Can a broker file a Marketplace appeal on behalf of a client?
Only with written client authorization. A verbal AOR is not sufficient for appeals work. The broker must have a signed written appointment of representative document, typically submitted with the appeal. Healthcare.gov's appeal form includes an authorized representative section. Without it, the Marketplace will not share appeal correspondence with the broker or accept broker submissions on the client's behalf.
What documentation resolves most income verification appeals?
A signed IRS Form 1040 for the most recent tax year or an IRS Tax Return Transcript obtained via Form 4506-C resolves most income verification failures. The Marketplace compares the MAGI on the application against IRS data. If the discrepancy is within 10 percent of the application amount, no action is needed. Beyond that threshold, primary IRS documentation is the fastest path to resolution. Pay stubs and employer letters are secondary; the IRS return is primary.
