FAQ about Appeals

It is your right to appeal if you feel that MNsure has made an incorrect decision or action about your application. MNsure will not retaliate against or penalize consumers for filing an appeal.

An appeal is asking for a fair review of your case, for example, if your application is denied.

A complaint is telling us you are unhappy with something connected to MNsure. Most complaints can be solved by speaking with the MNsure Contact Center or by talking with your community assister.

No.

Yes. Your appeal will be heard quickly if it qualifies. You have a right to request an "emergency expedited appeal" when health services are needed right away. Often, this is because a standard appeal could put the life or health of the person making the appeal at great risk. Or it could harm a person's ability to reach, maintain or get back full health. You will be asked if the appeal involves a medical emergency on the request form. If you have a medical emergency, check "yes" or call MNsure at: 561-539-2099 or 855-366-7873.

It is important to know that not all appeals will have a hearing. Currently, by law, certain types of appeals only require a desk review where the appeal examiner reviews hard copy evidence; the examiner will not consider live testimony. Right now, SHOP appeals are by desk review. Whether you receive a hearing is dependent on if a hearing is legally appropriate; and that is decided by the appeal examiner. You will receive a notice after filing your appeal and it will tell you whether or not a hearing is scheduled.

You will receive a scheduling order by mail informing you of the date and time of the hearing. If the hearing will take place by phone, a phone number will be provided for you to call. For in-person hearings, a location will be provided. The scheduling order will be sent at least 15 days before the hearing. The hearing date can be changed by the appeals examiner. If you cannot come to the hearing, you must tell the appeals examiner. If you do not have a good reason for not coming the hearing your case will be dismissed. The appeals examiner will contact you if the hearing is rescheduled.

At a hearing, your side of the story will be heard by an impartial judge who will ensure that all parties have opportunity to be heard. This judge is called an "appeals examiner." The appeals examiner will run the hearing. There may be people at the hearing representing MNsure.

Each party can offer documents as evidence and question witnesses. When the parties have finished introducing evidence and making their arguments about the case, the appeals examiner will close the hearing. The appeals examiner will send a written recommended decision after the hearing.

You should explain to the appeals examiner why you disagree with MNsure and what you think should happen in your case. You can present any relevant documents to support your argument. If the hearing is by telephone, you will have provided the documents in advance, following the instructions in the scheduling order. You can call witnesses and question them, but the testimony must be relevant to the case. If you are calling witnesses they must be present at the hearing. A video overview of how to present your case in appeals (with a general description of a typical administrative appeal) is available online.

It is important that the appeals examiner remain neutral and impartial. The appeals examiner cannot discuss your case with you or the other party unless all parties or their representatives can hear what is being said. This includes "hypothetical" questions about issues in your case. The appeals examiner can discuss with you matters such as hearing dates, deadlines, and arranging for an accommodation or an interpreter. Any time you write to the appeals examiner you must send a copy to the other parties. If you are unsure if it is proper to call an appeals examiner, you may contact the appeals office at the number provided in your notices.

MNsure will send you a written notice of the decision within 90 days of when you filed the appeal.

Call the MNsure Contact Center at 651-539-2099 or 855-366-7873 and describe the records or data you are requesting. The appeals representative assigned to your hearing will call you to further coordinate your request.

Yes. If you need language services during the appeal, you should call or write your appeals examiner as soon as you can. Tell the appeals examiner what help you need. The examiner will make sure that an interpreter is at the hearing. Also, let the judge know of any disability services you need to reasonably assist you at a hearing. You do not have to pay for these services.

Yes. An appeal is dismissed if you fail to appear at the hearing, fail to submit a valid appeal request, withdraw the appeal, or die before the appeal is completed. If you receive a dismissal order, you have 30 days to show that there is a good reason to reinstate your appeal. To have your appeal reinstated you must send a request to vacate the dismissal within 30 days of the dismissal order. You must provide information showing there is a good reason to continuing your appeal.

No. You can represent yourself if you want to. You can also have someone else speak for you. But you must be present at the hearing.

Yes, depending on the dispute, you may have access to appeal systems other than MNsure, such as private health plans, federal agencies, such as the Department of Health and Human Services, and state agencies, including the Minnesota Department of Human Services, Minnesota Department of Health and the Minnesota Department of Commerce.

No. When you have health insurance through your employer or purchased outside of the MNsure, disputes are resolved through the health plan, the Minnesota Department of Commerce or the Minnesota Department of Health. These kinds of disputes include coverage for children ages 21-26, coverage for some disabled children over age 26, entitlement to continuation of coverage through COBRA, and denial of claims or refusal of preapproval for particular medical procedures.

If Minnesota consumers believe a specific service should be covered by their health plan, they have the right to appeal directly to the health plan. If the plan denies the appeal, consumers can request an external review through the Minnesota Department of Commerce (if insured by a commercial insurance company) or the Minnesota Department of Health (if insured by an HMO). If you have further questions about how to direct your dispute, consider directly contacting these agencies directly. You may also contact the Consumer Response Team at the Minnesota Department of Commerce at 1-800-657-3602

If you think someone involved with MNsure is taking part in any form of fraud, waste, abuse or ethical violation, you can file a complaint. You can file even if the events happened in the past. To file a fraud report/complaint, send a message to mnsurecompliancehotline@mnsure.org. Please provide as much information as you can.

You may withdraw an appeal orally or in writing. Contact the appeals examiner assigned to your appeal.

Yes, definitely. Report all changes that may affect the appeal. This includes any changes in your current or projected income or household income.

You can appeal eligibility decisions made by MNsure. These can be decisions about:

• if a person qualifies to enroll in a program through MNsure, including qualified health plans, advance payment of premium tax credits, cost-sharing reductions, Medical Assistance, and/or MinnesotaCare;
• the amount of advance payment of premium tax credits or cost-sharing reductions figured by MNsure;
• claims related to Medical Assistance and MinnesotaCare through MNsure;
• if MNsure took too long to make an eligibility decision.

You must file your appeal within 90 days of the date on your eligibility determination notice (a/k/a Health Care Notice). If your appeal involves Medical Assistance or MinnesotaCare, there is less time. You must file your appeal within 30 days of the date on your eligibility determination notice or within 90 days if you can show good cause for filing late.

Only if you ask us for this. In appeals where your eligibility was redetermined, you will only receive the level of eligibility you received before the redetermination decision you are appealing if you ask us to.

Which benefits or eligibility are affected is determined by which program it is that you are appealing :

• If appealing a Medical Assistance or MinnesotaCare determination, it refers to eligibility and program benefits;
• If appealing an advanced payment of premium tax credits and/or cost-sharing reduction determination, it is the level of advance payment of premium tax credits and/or cost-sharing reductions;
• If appealing the eligibility to purchase a QHP through MNsure, it is the eligibility to purchase a QHP through MNsure that is affected.

Based on the type of program you get through MNsure, there may be time limits connected with appeals. If you lose your appeal, you may have to pay back the extra benefits you receive. See your Health Care Notice for more details.

As an employer, you can appeal the determination explained in the employer notice. Employers may appeal:

• The determination that the employer does not provide minimum essential coverage through an employer-sponsored plan, or
• The determination that the employer provides coverage but it is not affordable coverage with respect to an employee.

You must file your appeal within 90 days of the date of your MNsure employer notice.

MNsure determined the employee listed on the employer notice is eligible for advanced premium tax credits (APTC). The employee listed in the employer notice reported on his or her MNsure application that his or her employer does not provide minimum essential coverage or it is unaffordable. Federal law requires MNsure to send the employer notice to employers whose employees qualify for APTC, and provide a right to appeal the determination in the notice.

Employers with 50 or more full-time employees might be liable to the U.S. Department of the Treasury for a payment assessed under the employer shared responsibility provisions (26 U.S.C. 4980H). The Internal Revenue Service (IRS) will determine whether the employer is liable under the employer shared responsibility provisions. MNsure is not responsible for making any determination regarding the employment status of the employee or liability of the employer under the employer shared responsibility.

No, you are invited to participate, but not required. However, the result of the appeal may cause MNsure to redetermine your household's eligibility for advanced payment of tax credits.

If you are an employee, consider using this Employee Appeal Fact Sheet (PDF) to help you prepare. ​

If you are an employer, talk to your business' legal counsel and/or tax preparer. This fact sheet may also help: Employer Appeal Fact Sheet (PDF).