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:

English | Spanish

  • Alabama
  • Alaska
  • Louisiana
  • Montana
  • Virginia
  • West Virginia
  • Wyoming

Appeal Request Form for the following states:

English | Spanish

  • 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):

English | Spanish

  • California
  • Colorado
  • Connecticut
  • District of Columbia
  • Idaho
  • Kentucky
  • Maine
  • Maryland
  • Massachusetts
  • Minnesota
  • Nevada
  • New Jersey
  • New Mexico
  • New York
  • Pennsylvania
  • Rhode Island
  • Vermont
  • Washington