Eligibility appeals forms
Eligibility appeals forms
To file an appeal, complete and submit the form online, or download and complete the form for your state and mail it to the Marketplace.
Appeal Request Form for the following states:
- Alabama
- Alaska
- Louisiana
- Montana
- Virginia
- West Virginia
- Wyoming
Appeal Request Form for the following states:
- Arizona
- Arkansas
- Delaware
- Florida
- Georgia
- Hawaii
- Illinois
- Indiana
- Iowa
- Kansas
- Michigan
- Mississippi
- Missouri
- Nebraska
- New Hampshire
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Wisconsin
Appeal Request Form for the following states (Use this form only after you’ve used up all of your eligibility appeal rights with your state):
- California
- Colorado
- Connecticut
- District of Columbia
- Idaho
- Kentucky
- Maine
- Maryland
- Massachusetts
- Minnesota
- Nevada
- New Jersey
- New Mexico
- New York
- Pennsylvania
- Rhode Island
- Vermont
- Washington
Page Last Modified:
09/10/2024 06:18 PM