29. What happens after an appeal is filed?

If benefits are reduced or terminated at the annual redetermination or after a redetermination based on a report of a change or periodic data match the appellant is entitled to have benefits continued pending appeal at the level of benefits prior to the redetermination. Aid pending appeal is available so long as the member filed a valid appeal received by the Connector within 35 days of the date on the notice.  45 CFR 155.525.  However, if the appeal is unsuccessful, the appellant may have to repay advance premium tax credits received pending appeal through the reconciliation process described in Q & A 30. 

The appellant is entitled to at least 15 days’ notice of the hearing unless he or she has asked for an expedited appeal. The appellant has the right to review the case file and all information to be presented at the hearing in advance. At the hearing, the appellant may bring witnesses, and cross-examine witnesses. The appeal is de novo meaning that the hearing officer considers not just evidence used in making the initial decision but all additional evidence presented at the hearing relevant to the issue on appeal. 45 CFR 155.535. 

The appeal decision must be in writing, based on the evidence and the applicable regulations, and must ordinarily be issued within 90 days of the appeal request, or in the case of an expedited appeal, as soon as possible. 

Upon receiving the decision, the Connector must implement the decision on the first of the following month or an earlier date as determined by the hearing officer. The hearing officer may order a retroactive enrollment date, however, the appellant may elect not to have a retroactive effective date. For example, the appellant may not want to pay premiums for a past period in which he or she incurred no medical expenses, and may instead elect a future effective date. The Connector must also redetermine the eligibility of other household members who did not appeal but whose eligibility may be affected by the decision. 45 CFR 155.545.