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Responding to the Washington Health Benefit Exchange regarding an employee’s eligibility for a premium tax credit

If you receive a notice from the Washington State Health Benefit Exchange finding that one of your employees is eligible for a premium tax credit (federal subsidy) to help purchase a qualified health plan (QHP) at the Exchange, you may wish to appeal the decision.

If you have less than 50 employees, or if the employee works less than 30 hours per week, an appeal to the Exchange is not necessary since you are not subject to pay-or-play penalties.

If you have 50 or more employees, and the employee works 30 hours or more a week, an appeal to the Exchange is warranted since you are subject to the pay-or-play penalties. All plans offered through the Trust provide minimum essential coverage. If the employee is enrolled on a Trust plan, or was offered and declined coverage on a Trust plan, they would be ineligible for the subsidy.

By filing an appeal, you may be able to head off a determination from the IRS that you owe pay-or-play penalties. If the IRS imposes a pay-or-play penalty, you may contest such penalty before the IRS, whether or not you have filed a formal appeal with the Exchange.

If you wish to contest the decision of the Exchange, start by contacting Exchange employees at the Appeal Program. You can reach the Appeals Program at 1-855-859-2512.

If you are unable to resolve the matter informally and decide that filing an appeal is in your best interest, you have 90 days from the date on the notification to request a hearing by filing an Employer Request for Hearing Form. When you file the hearing request, you may also wish to notify your employee that you are filing an appeal. Here is a sample letter that Trust attorneys have reviewed for your use.

Once granted, the hearing may be done over the phone or in person with a Washington Health Benefit Exchange Presiding Officer and will include you and the employee. You and/or your employee may also have a lawyer present at the hearing. To learn more about the process, click here and the FAQs on Exchange appeals.