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Text of Health Insurance Marketplace Employer Appeal Request Form (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Aug. 5, 2016

"If you received a Marketplace notice stating that you may be subject to the Employer Shared Responsibility Payment, you can request an appeal by submitting this form ... This appeal may determine if an employee was eligible for help with the costs of coverage through the Marketplace at the same time that you may have offered them affordable health coverage that met the minimum value standard. This appeal will NOT determine if your organization has to pay the Employer Shared Responsibility Payment."

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