Fair Hearing Resources

New York State of Health (NYSOH) Appeal Decisions

Article ID: 56
Last updated: 29 May, 2016

by Gene Doyle, LMSW

Since January 1, 2014, the New York State Department of Health (DOH) has administered the New York State of Health (NYSOH), a state-run health exchange (or health insurance marketplace), established under the federal Patient Protection and Affordable Care Act (ACA), also known as "Obamacare."

Anyone who applies for Medicaid or other health insurance through NYSOH is entitled to challenge an eligibility determination through an administrative appeal. According to DOH's Guide to the Appeal Process, the following NYSOH decisions can be appealed:

  • Decision that you do not meet the rules to buy a health plan for yourself or your family in the Marketplace. Example: You do not live in New York State, or are incarcerated.
  • Decision that you do not meet the rules for getting federal help paying for a health plan purchased in the Marketplace.
  • Decision on how much you must pay for your monthly premium if you applied for financial help.
  • Decision that you do not meet the rules for coverage under Medicaid or Child Health Plus.
  • Decision on how much money you must pay for Child Health Plus coverage if your children are eligible for this program.
  • Decision that you do not meet the rules for signing up for insurance in the Marketplace during a “special enrollment period.”
  • Delayed decision by the Marketplace. Example: You did not get a notice telling you if you meet the rules for Medicaid coverage within the required 45 days.
  • Decision to change any earlier decision made by the Marketplace.
  • Decision that your appeal request is not valid.

Pursuant to 45 CFR § 155.550(b), DOH "must provide public access to all appeal decisions, subject to all applicable Federal and State laws regarding privacy, confidentiality, disclosure, and personally identifiable information."

By letter dated May 24, 2016, DOH announced that redacted copies of NYSOH appeal decisions will be posted online "in a manner similar to the Fair Hearing Decision Archive administered by the Office of Temporary and Disability Assistance (OTDA)." In that letter, DOH reported

"that work has already begun on a webpage for NYSOH appeals decisions that will function in the same manner as OTDA's and that Marketplace staff is currently in the process of redacting decisions for posting on that webpage. We expect to have redacted decisions issued during the latter part of 2015 ready for posting by the end of June. We will populate the website in reverse monthly order until we complete 2015, and then will move into decisions from 2014 and 2016. When the webpage goes live, we will send you the URL for the page."

Under New York's State Administrative Procedure Act (SAPA) § 307[3], DOH must also maintain an index of NYSOH appeal decisions, and make the index and redacted copies of the decisions available for public inspection and copying.

In response to a Freedom of Information Law (FOIL) request, DOH provided an Index of NYSOH Decisions and Dismissals on March 14, 2016. This index includes both NYDOH appeal decisions and dismissals from January 8, 2014 through February 26, 2016.

The following table explains the issue codes found in the Index of NYSOH Decisions and Dismissals:

Issue Code Explanation
Explanation of Issue Codes
APTC Advance Premium Tax credit
CHP Child Health Plus
CSR Cost Sharing Reduction
EED CSR Cost Sharing Reduction
ESD EED Enrollment End Date
ESI Employer- Sponsored Insurance
FFS Fee for Services
MA - Wants In Medicaid- Wants Out
MA - Wants out Medicaid- Wants Out
MAGI Modified Adjusted Gross Income
MEC Minimum Essential Coverage
MMC Managed Care Plan
PAP Premium Assistance Program
QHP Qualified Health Plan
SBM Small Business
SEP denial Special Enrollment Period

Redacted copies of the following NYSOH appeal decisions are available by clicking on the Appeal Number (AP #):

Appeal Number Issue Date
New York State of Health Appeal Decisions
AP000000003521 MA - wants in 02/23/16
AP000000004418 MA - wants in 02/24/16

More decisions will be posted as they are obtained from appellants and their advocates or through FOIL requests to DOH.

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Article ID: 56
Last updated: 29 May, 2016
Revision: 5
Views: 0
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