New York Laws
Title 7 - Ny State of Health
268-E - Appeals and Appeal Hearings; Judicial Review.

(a) applicants for or enrollees in insurance affordability programs
and qualified health plans; and
(b) other persons entitled to an opportunity for an appeal hearing as
directed by the commissioner.
4. An applicant or enrollee has the right to appeal at least the
following issues:
(a) An eligibility determination made in accordance with this article
and applicable law, including:
(i) An initial determination of eligibility, including:
(A) eligibility to enroll in a qualified health plan;
(B) eligibility for Medicaid;
(C) eligibility for Child Health Plus;
(D) eligibility for the Basic Health Program;
(E) the amount of advance payments of the premium tax credit and level
of cost-sharing reductions;
(F) the amount of any other subsidy that may be available under law;
and
(G) eligibility for such other health insurance programs as determined
by the commissioner; and
(ii) a re-determination of eligibility of the programs under this
subdivision.
(b) An eligibility determination for an exemption for any mandate to
purchase health insurance.
(c) A failure by NY State of Health to provide timely written notice
of an eligibility determination made in accordance with applicable law.
5. The department may, subject to the discretion of the commissioner,
promulgate such regulations, consistent with federal or state law, as
may be necessary to implement the provisions of this section.
6. Regarding every decision of an appeal pursuant to this section, the
department must inform every party, and his or her representative, if
any, of the availability of judicial review and the time limitation to
pursue future review.
7. Applicants and enrollees of qualified health plans, with or without
advance payments of the premium tax credit and cost-sharing reductions,

also have the right to appeal to the United States Department of Health
and Human Services appeal entity:
(a) appeals decisions issued by NY State of Health upon the exhaustion
of the NY State of Health appeals process; and
(b) a denial of a request to vacate a dismissal made by the NY State
of Health appeals entity.
8. The department must include notice of the right to appeal as
provided by subdivision four of this section and instructions regarding
how to file an appeal in any eligibility determination issued to the
applicant or enrollee in accordance with applicable law. Such notice
shall include:
(a) an explanation of the applicant or enrollee's appeal rights;
(b) a description of the procedures by which the applicant or enrollee
may request an appeal;
(c) information on the applicant or enrollee's right to represent
himself or herself, or to be represented by legal counsel or another
representative;
(d) an explanation of the circumstances under which the appellant's
eligibility may be maintained or reinstated pending an appeal decision;
and
(e) an explanation that an appeal decision for one household member
may result in a change in eligibility for other household members and
that such a change will be handled as a redetermination of eligibility
for all household members in accordance with the standards specified in
applicable law.