File an Appeal or a Complaint

Get the right help for your issue.

Do you need to file an appeal or complaint, have an insurance plan issue, or need help with an unresolved case? Not every problem follows the same process. Choose the option that best matches your issue so you can get the right help faster.

File an Appeal

Choose this option if you disagree with a Covered California eligibility determination, or if a Covered California action or failure to act affected your health insurance or financial help.

Your eligibility notice explains what you qualify for and which programs you do not qualify for. If you think Covered California made a mistake about your eligibility, filing an appeal is the right next step.

You generally must file your appeal within 90 days of the date Covered California mailed your eligibility decision.

To file an appeal, fill out and mail us an appeal form. Instructions can be found on the form.

File a Complaint

Choose this option for problems with Covered California’s service, website, enrollment process, a service center representative or a certified enroller or agent.

This option is not for disputing an eligibility determination.

To file a complaint, fill out the online complaint form. You can also contact us if you have questions.

Contact Your Insurance Company

Choose this option for questions about monthly premiums, billing, claims, provider networks, covered services, benefits, membership ID cards or other plan-specific issues.

Find phone numbers and contact information for all health, dental, and vision plans on our Insurance Company Contacts page.

Contact the Ombuds Office

Choose this option only after you have contacted the Covered California Service Center and your issue remains unresolved.

Visit the Ombuds Office page to learn how to open a case.

Reasons for Filing an Appeal

Your eligibility notice explains what you qualify for and what you don’t qualify for. You may be able to file an appeal if any of these apply to you:

Coverage or Enrollment Decisions

• You were denied enrollment in a health plan through Covered California.
• Your insurance ended because of a mistake made by Covered California, an agent, a certified enroller or the insurance company.

Financial Help or Out-of-Pocket Cost Decisions

• The amount of financial help you were approved for is not correct.
• The level of cost-sharing reductions you were approved for is not correct.

Application Processing or Notice Timing

• Covered California did not process your application, or the information you submitted, on time.
• Covered California said your application was incomplete and you do not agree.

Identity, Residency, Income and Other Eligibility Decisions

You can file an appeal if you believe that Covered California made a mistake in deciding your eligibility or got something wrong. This applies if Covered California said you are not eligible because:

• You are not a U.S. citizen, U.S. national or lawfully present person living in the United States.
• You are not a California resident.
• Your income is too low to qualify for insurance through Covered California.
• You don’t qualify for financial help because you’re eligible for or enrolled in other insurance, such as Medi-Cal, Medicare or job-based insurance.
• You don’t qualify for an exemption from California’s individual mandate.
• You don’t qualify for special enrollment because Covered California said you didn’t have, or didn’t prove, a major life change.
• You didn’t pay your monthly premium by the due date.

What Happens After You File

After You File an Appeal

Covered California may contact you first to see if the issue can be resolved before a hearing is scheduled. If the issue is not resolved, the California Department of Social Services will schedule a hearing with an administrative law judge.

For most appeals, the hearing process and decision take up to 90 days from the date we get a valid appeal request. After the hearing, the judge reviews the information and mails you a final decision.

Hearings are usually held by phone, unless you ask for an in-person hearing. You can represent yourself or have an attorney or another representative help you.

After You File a Complaint

Covered California will review your complaint and respond within 30 business days.

If you don’t get a response or update within that timeframe, you can contact the Ombuds Office for help.

Downloadable Forms

Appeal Forms

Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination (PDF)

Complaint Forms

• File a Complaint Online
• Bilingual Services Complaint Form (PDF)
• Privacy Complaint Form (PDF)
• Privacy Complaint by a Parent, Guardian, or Authorized Representative (PDF)