45 CFR 155.555 - Employer appeals process.
(a)General requirements. The provisions of this section apply to employer appeals processes through which an employer may, in response to a notice under § 155.310(h), appeal a determination that the employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide that coverage but it is not affordable coverage with respect to an employee.
(b)Exchange employer appeals process. An Exchange may establish an employer appeals process in accordance with the requirements of this section and §§ 155.505(f) through (h) and 155.510(a)(1) and (2) and (c). Where an Exchange has not established an employer appeals process, HHS will provide an employer appeals process that meets the requirements of this section and §§ 155.505(f) through (h) and 155.510(a)(1) and (2) and (c).
(2) Allow an employer to submit relevant evidence to support the appeal;
(4) Comply with the requirements of § 155.520(a)(1) through (3); and
(5) Consider an appeal request valid if it is submitted in accordance with paragraph (c)(1) of this section and with the purpose of appealing the determination identified in the notice specified in § 155.310(h).
(d)Notice of appeal request.
(ii) Send timely notice to the employee of the receipt of the appeal request, including -
(A) An explanation of the appeals process;
(B) Instructions for submitting additional evidence for consideration by the appeals entity; and
(C) An explanation of the potential effect of the employer's appeal on the employee's eligibility.
(2) Upon receipt of an invalid appeal request, the appeals entity must promptly and without undue delay send written notice to the employer that the appeal request is not valid because it fails to meet the requirements of this section. The written notice must inform the employer -
(i) That the appeal request has not been accepted;
(ii) About the nature of the defect in the appeal request; and
(iii) That the employer may cure the defect and resubmit the appeal request by the date determined under paragraph (c) of this section, or within a reasonable timeframe established by the appeals entity.
(iv) Treat as valid an amended appeal request that meets the requirements of this section, including standards for timeliness.
(e)Transmittal and receipt of records.
(1) Upon receipt of a valid appeal request under this section, or upon receipt of the notice under paragraph (d)(1)(iii) of this section, the Exchange must promptly transmit via secure electronic interface to the appeals entity -
(ii) The employee's eligibility record.
(f)Dismissal of appeal. The appeals entity -
(2) Review -
(i) The information described in § 155.310(h)(1);
(ii) Information regarding whether the employee's income is above or below the threshold by which the affordability of employer-sponsored minimum essential coverage is measured, as set forth by standards described in 26 CFR 1.36B; and
(h)Confidentiality of employee information. Neither the Exchange nor the appeals entity may make available to an employer any tax return information of an employee as prohibited by section 6103 of the Code.
(i)Adjudication of employer appeals. Employer appeals must -
(1) Be reviewed by one or more impartial officials who have not been directly involved in the employee eligibility determination implicated in the appeal;
(2) Consider the information used to determine the employee's eligibility as well as any additional relevant evidence provided by the employer or the employee during the course of the appeal; and
(3) Be reviewed de novo.
(j)Appeal decisions. Employer appeal decisions must -
(2) State the decision, including a plain language description of the effect of the decision on the employee's eligibility; and
(3) Comply with the requirements set forth in § 155.545(a)(3) through (5).
(1) The employer. Such notice must include -
(i) The appeal decision; and
(2) The employee. Such notice must include -
(i) The appeal decision; and
(ii) An explanation that the employee and his or her household members, if applicable, may appeal a redetermination of eligibility that occurs as a result of the appeal decision.
(3) The Exchange.
(1) Redetermine the employee's eligibility and the eligibility of the employee's household members, if applicable, in accordance with the standards specified in § 155.305; or
(2) Notify the employee of the requirement to report changes in eligibility as described in § 155.330(b)(1).
(m)Appeal record. Subject to the requirements of § 155.550 and paragraph (h) of this section, the appeal record must be accessible to the employer and to the employee in a convenient format and at a convenient time.