It is your right to appeal if you feel that Get Covered Illinois has made an incorrect decision or action about your application. Get Covered Illinois will not retaliate against or penalize customers for filing an appeal.
How do I file an appeal?
To file your appeal, please fill out and submit an Appeal Request Form. If you are unable to obtain this form online, you can call the Get Covered Illinois customer assistance center at 1-866-311-1119 (TTY: 711).
Your appeal must include your name, address, and a detailed reason why you believe the marketplace's eligibility determination is in error. If you are requesting an appeal for someone else (like your child), also include their name.
You can submit the Appeal Request Form in one of the ways listed below:
Online: Visit GetCoveredIllinois.gov and log in to your account.
- Navigate to My Tickets
- Click on Submit New Ticket
- Select your request type and request subtype:
- Request Type: Issue
- Request Subtype: Complaint or Question
- In the subject line, enter: Marketplace Appeal
- In the description box, briefly explain the reason for your appeal
- Submit the ticket. Once submitted, you’ll receive a Ticket ID.
- Attach your Appeals Request Form and any supporting documentation to the ticket using the Add Attachment feature.
Fax to Get Covered Illinois at: 1-888-973-8254
Mail your appeal to:
Get Covered Illinois
Attn: Marketplace Appeals Program
P.O. Box 804058
Chicago, IL 60680
Appeal timing
An appeal is considered timely if Get Covered Illinois receives it within 90 days from your receipt of the notice of eligibility determination. Get Covered Illinois presumes that the notice is received five (5) business days after the date printed on the notice. Therefore, appeals received within 95 calendar days from the notice date are generally treated as timely.
If you believe you’ve received the notice more than five business days after the printed date, you may rebut the presumption by submitting:
- Testimony, and/or
- Documentary evidence (such as a postmarked envelope or delivery receipt).
In most instances, you can’t file an appeal until you get your eligibility notice, which will state your eligibility for coverage, tax credits or cost sharing benefits. The eligibility notice will also describe your appeal rights.
What can I appeal?
You have the right to file an appeal of any final eligibility determination from Get Covered Illinois. You can appeal, among other things, a decision to deny, terminate or change:
- An initial eligibility determination, including:
- Eligibility to enroll in a qualified health plan (QHP) through Get Covered Illinois;
- The amount of advanced payments of the premium tax credit (APTC);
- The level of cost-sharing reductions (CSR), or
- Denial of a special enrollment period (SEP)
- A redetermination of eligibility, including changes to APTC, CSR level or SEP eligibility
- Effective date of APTC or QHP coverage, if you believe it was incorrectly assigned or delayed (such as due to system error or misapplication of effective date rules)
- Failure by Get Covered Illinois to provide a timely notice of an eligibility determination
- Denial of a request to vacate a dismissal issued by the Get Covered Illinois appeals program
- Termination of QHP coverage due to a marketplace eligibility determination (e.g., loss of APTC or failure to verify required information)
Please note that only final eligibility determinations from Get Covered Illinois are appealable.
Who Can File an Appeal?
You can file an appeal for yourself or for someone else on your application. An authorized representative can help you complete your appeal form and represent you in the appeals process. The representative may be a friend, family member or someone else you trust.
You may designate an authorized representative by completing the Authorized Representative Form, and submitting it through your Get Covered Illinois account, or by one of the methods below:
Fax to Get Covered Illinois at: 1-888-973-8254
Mail to:
Get Covered Illinois
Attn: Marketplace Appeals Program
P.O. Box 804058
Chicago, IL 60680
Does it cost me anything to file an appeal?
No.
What is the difference between an appeal and a complaint?
An appeal is asking for a fair review of your case, for example, if your application is denied.
A complaint is telling us you are unhappy with something connected to Get Covered Illinois. Most complaints can be solved by calling the Get Covered Illinois customer assistance center at 1-866-311-1119 (TTY 711). You can also reach out to a Get Covered Illinois certified broker or navigator.
Can I expedite my appeal?
Yes. You may request an expedited appeal if you can show an immediate need for health care services because a standard appeal could jeopardize your life, health or ability to attain, maintain or regain maximum function.
Examples would include but are not limited to:
- Pregnancy and postpartum care
- Prescriptions for chronic illnesses or life-threatening conditions
- Dialysis
- Cancer treatment
- Broken bones needing immediate treatment
- Prescriptions for serious mental health conditions
- Non-elective surgery
- Severe mood and neurological disorders (e.g., schizophrenia, bipolar disorder)
- Other similar conditions or circumstances.
What supporting documents do I need?
Your supporting documents may include, but are not limited to, the items listed below.
If Get Covered Illinois determined you were not eligible for coverage because you did not submit documents proving citizenship or immigration status:
- Permanent Resident Card (Form I-551)
- Employment Authorization Card (Form I-766)
- Unexpired U.S. or Foreign Passport
- Driver’s License or State ID along with U.S. Birth Certificate
- Notice of Action (Form I-797)
- Arrival/Departure Record (Form I-94)
- Certificate of Citizenship (Form N-560/N-561)
- American Indian Card (Form I-872)
If Get Covered Illinois determined you were not eligible to enroll in or change plans through Get Covered Illinois outside of the Open Enrollment Period (OEP), and you were deemed ineligible for a Special Enrollment Period (SEP). If the reason you believe you should be allowed to enroll is that you:
- Lost or are losing coverage: A letter from the insurance carrier or the agency that administered the insurance, showing the last day of coverage.
- Had Medicaid but were deemed ineligible: denial or termination letter.
- Got married: A marriage certificate, marriage license, or signed affidavit.
- Had a baby, adopted a child, or were placed with a child for foster care: A birth certificate, hospital records, adoption certificate, child support order or court order
- Had a permanent move: Documentation that displays the updated address, such as a driver’s license, state ID, lease agreement, mortgage payment receipt or utility bill
If Get Covered Illinois determined you were not eligible for financial assistance, or you disagree with the amount approved, provide documentation to verify your income. This may include one of the following:
- Tax return
- Pay stub
- W-2
- Social Security benefit statement
- Self-employment ledger, including the name of the person who earned the income, company name, dates for which the income was received and the net amount of profit or loss)
You may also submit additional documents that you think support your appeal. Submit copies, not original documents. Include your first and last name, and ticket number (TIC-XXXXX, this is located in your portal in the “My Tickets” section) on all documents you submit.
What happens after I submit my appeal request form?
After you submit your Appeal Request Form, Get Covered Illinois will contact you to let you know whether we have everything we need to process your appeal. Once we have everything required, we will review your appeal and notify you of our decision, along with any next steps.
Informal Resolution: A representative from Get Covered Illinois will contact you to attempt to resolve your appeal. If you do not agree with the outcome of the informal resolution, you may request to escalate your appeal to a formal hearing instead. Most customer appeals are resolved to the customer's satisfaction through the informal review.
Formal Hearing: If you choose not to participate in the informal resolution process or are unable to resolve your appeal during that phase, a representative will contact you to schedule your appeal hearing and will confirm the date and time of your hearing in a written Notice of Hearing.
Withdrawal of an appeal: You may cancel or end your appeal any time before the Hearing Officer issues a decision – this is known as a withdrawal of an appeal. Complete the Request to Withdraw Hearing Form or call the Get Covered Illinois customer assistance center if you wish to withdraw your appeal/hearing request.
Representation during an appeal: You have the right to have an authorized representative, including a lawyer, to help you with your appeal. Get Covered Illinois will not provide a lawyer for you. Your authorized representative is a trusted person you choose who has your permission to discuss your appeal with Get Covered Illinois, see your information and act for you on matters related to your appeal, such as signing your Appeal Request Form or making arguments on your behalf at the hearing. If you want to have an authorized representative participate in your appeal, you must submit an authorized representative form to designate a representative in a separate document.
Do I need to report changes during my appeal?
Yes, you may report any changes to your application that may affect your appeal. Changes you may report include, but not limited to, your current or projected income or household income, household members, or address.
To report a change:
- Log in to your account at GetCoveredIllinois.gov.
- Navigate to the Next Steps section
- Update your application
How am I notified if my appeal is eligible for a hearing?
All customers with valid appeal requests are entitled to a hearing. Once a hearing is scheduled, you will receive a Notice of Hearing from a Department of Insurance Hearing Office with the date, time and hearing location (conducted virtually via Webex). You will receive notice of the formal hearing at least 15 days prior to the scheduled hearing, unless the matter is an expedited appeal, if so, those are scheduled 10 days in advance.
What if I want to reschedule my hearing?
Requests to reschedule a hearing may be submitted by email to your assigned hearing officer, via telephone with the Get Covered Illinois customer assistance center, or through your Get Covered Illinois customer account. Requests may be made verbally or in writing.
Rescheduling of a hearing is granted solely at the discretion of the Hearing Officer.
Will I be offered legal counsel? Do I Need a Lawyer?
No. Get Covered Illinois does not provide legal counseling during the appeals proceedings. However, you are eligible to appoint an authorized representative to assist or act on your behalf during the appeals process. Your authorized representative may be a legal counsel, relative, friend, caseworker, navigator, certified application counselor or other designated individual. The authorized representative may communicate with Get Covered Illinois, submit appeal requests and documentation and attend or represent you during informal resolution and formal hearings.
You can submit your request for an authorized representative using the Get Covered Illinois Authorized Representative Form.
Your authorized representative is responsible for:
- Providing information and documents
- Returning phone calls, attending pre-hearing conferences and any other actions for your appeal
- Telling Get Covered Illinois what you want to do once you have appeal results, like what plan you want to enroll in, etc.
A lawyer or authorized representative is not required for appeal proceedings. You can represent yourself throughout the appeals process. While you can have someone else speak for you throughout the appeals process, you must be present at the hearing.
Are language services and/or disability accommodations provided for during the appeals process?
Yes. If you need language assistance in a language other than English, you have the right to get help and information in your language at no cost. Call the Get Covered Illinois customer assistance center at 1-866-311-1119 (TTY: 711) to access language assistance services.
If you need language services during the Hearing, you should call or write your Hearing Officer as soon as you can and request services you need. The Hearing Officer will ensure that interpretive services are available at hearing. Also, let the Hearing Officer know of any disability services you need to reasonably assist you at your hearing. These services are available free of charge.
What happens at the hearing?
At the hearing, you will have the opportunity to explain in detail why you are requesting an appeal. The hearing will be conducted by an impartial administrative law judge (ALJ), called the Hearing Officer, who will make sure everyone has a chance to speak. The Hearing Officer will guide the hearing, and a representative from Get Covered Illinois will also be present.
Each side may submit documents as evidence and question witnesses. After all evidence is presented and both sides have made their arguments, the Hearing Officer will close the hearing. The Hearing Officer will then prepare findings of fact, and the Director of the Illinois Department of Insurance will issue a final decision.
How do I present my case?
You should explain to the Hearing Officer why you disagree with Get Covered Illinois and what you think should happen in your case. You can present any relevant documents to support your argument, which should be submitted before the hearing, following the instructions in the Notice of Hearing. You can call witnesses and question them, but the testimony must be relevant to the case. If you are calling witnesses, they must be present at the hearing.
Can I ask the Hearing Officer for help with my case?
The Hearing Officer must remain neutral and cannot take sides. They are not allowed to discuss your case with you or the other party unless everyone (or their representatives) is present and can hear the conversation. This rule also applies to hypothetical questions about your case.
The Hearing Officer may communicate with you about scheduling matters, such as hearing dates, deadlines or requests for accommodations or an interpreter.
Whenever you send written communication to the Hearing Officer, you must also send a copy to the other parties.
If you are unsure whether it is appropriate to contact the Hearing Officer, you may contact the Get Covered Illinois Marketplace Compliance & Program Integrity team using the contact information in your notice.
How will I know what the decision is and how long will it take?
Get Covered Illinois will send you a written notice of the Director’s decision within 90 days of when you filed the appeal, or as administratively feasible.
What if I change my mind and no longer wish to appeal?
You may withdraw your appeal by completing and submitting the Request to Withdraw Hearing Form via your Get Covered Illinois account or to the Get Covered Illinois Marketplace Compliance & Program Integrity team via contact information located in your Notice of Hearing, verbally via the Get Covered Illinois Customer Assistance Center at 1-866-311-1119 (TTY 711) or in writing to Get Covered Illinois.
Why was my appeal dismissed?
Dismissal of an appeal ends the appeal process. Get Covered Illinois may dismiss an appeal for any of the following reasons:
- Invalid appeal
- You withdrew your appeal
- Failure to appear at the hearing
- The death of the appellant
If you receive a dismissal order, you have 30 days to show that there is a good reason to reinstate your appeal. To have your appeal reinstated, you must send a request to vacate the dismissal within 30 days of the issuance of the dismissal order. You must provide information showing there is a good reason to continue your appeal.
For dismissals based on untimely appeals, Get Covered Illinois may vacate the dismissal if the appellant shows exceptional circumstances, such as those defined in 50 Ill. Adm. Code 4500.230(c)(2).
For more information on dismissals, please contact the Get Covered Illinois customer assistance center at 1-866-311-1119 (TTY: 711).
Equal Access to Get Covered Illinois Services
Get Covered Illinois commits to providing services that are accessible to everyone. We embrace diversity and respect the rights of all. We do not hold bias or discriminate based on, but not limited to, ethnicity, race, creed, color, religion, age, ability, sex, gender, marital status, nation of origin, political opinion or affiliation, veteran status or genetic information.
If you have questions about compliance or a complaint about bias, harassment or discrimination, contact our Compliance and Privacy Department:
Get Covered Illinois Marketplace Compliance & Program Integrity
ATTN: Marketplace Compliance & Program Integrity Coordinator
P.O. Box 804058
Chicago, IL 60680
Email: gci.compliance@illinois.gov
I have other health insurance. Can I use the Get Covered Illinois appeals process?
No. When you have health insurance through your employer or purchased outside of Get Covered Illinois, disputes are resolved through your health plan and/or the Illinois Department of Insurance. These kinds of disputes could include coverage for children ages 21-26, coverage for some disabled children over age 26, entitlement to continuation of coverage through COBRA and denial of claims or refusal of preapproval for particular medical procedures.
If any Illinois consumers believe a specific service should be covered by their health plan, they have the right to appeal directly to the health plan provider. If you have further questions about how to direct your dispute, consider contacting the agency directly.
What if I have a complaint about the appeal process that does not involve the decision?
If you have a complaint regarding the Get Covered Illinois appeal process, put the complaint in writing and send it to the Illinois Department of Insurance.
Get Covered Illinois or a representative from the DOI Office of Legal Affairs will respond to your complaint or refer the complaint to a separate agency for resolution.
What if I think that government fraud or abuse has occurred?
If you think someone involved with, Get Covered Illinois or an associated third-party is taking part in any form of fraud, waste, abuse or ethical violation, you can file a complaint. You can file even if the events happened in the past. To file a fraud report/complaint, send an email to gci.compliance@illinois.gov. Please provide as much information as you can when submitting your complaint.
Applicable laws and regulations
Marketplace eligibility, financial assistance and appeals are governed by federal and state laws. Customers who want more detailed information can review the laws and regulations below.
- Marketplace eligibility and enrollment regulations under 45 CFR Part 155
- Appeals regulations under 45 CFR Part 155.520 (Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs) (see Sections §§ 155.505–155.545)
Patient Protection and Affordable Care Act (Public Law No. 111-148, enacted March 23, 2010) - Establishes the health insurance marketplace and eligibility rules for coverage and financial help.
Recent changes to the Patient Protection and Affordable Care Act are noted in the One Big Beautiful Bill Act, PUBLIC LAW 119–21, enacted July 4, 2025, formerly referred to as H.R. 1.
Illinois Administrative Code, Section 4500.230 Eligibility Appeals sets out the requirements for appeals of eligibility determinations issued by the Exchange, d/b/a Get Covered Illinois.
45 CFR §155.305(a)(1) Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act: Eligibility standards
45 CFR §155.305(f) Eligibility for advance payments of the premium tax credit
26 U.S.C. §36B Refundable credit for coverage under a qualified health plan
50 ILL Adm Code 4500.190 Eligibility and Special Rules on Advanced Payments of the Premium Tax Credit and Cost-Sharing Reductions
Appeal Documents
- Appeal Request Form
- Request to Withdraw Eligibility Appeal Form
- Authorized Representative Form
- Continued Enrollment Form
Disclaimer
This information is provided for educational and general informational purposes only. It is not intended to serve as legal advice and should not be relied upon as a substitute for consulting a qualified attorney or other legal professional. Laws and procedures may change, and the application of law can vary based on individual circumstances. For advice about your specific situation, you should contact a licensed attorney or appropriate professional.