Forms & Tax Information

To request an appeal, fill out the Appeals Request Form below and mail it to the address listed.

Once you file an appeal, you will receive a formal ‘Acknowledgement of Appeal Notice’ based on your Marketplace communication preference which confirms your intent to appeal and includes additional information about the appeals process. CoverME.gov will then mail you a notice telling you when a hearing before an independent Administrative Hearings Officer will occur in your case. This is a hearing that you must attend, whether it is conducted virtually or in-person.

The hearing will remain scheduled unless you contact CoverME.gov at 1-866-636-0355 (TTY: 711) to cancel it. At your hearing, you can testify, have others testify for you, and submit documents. CoverME.gov representatives can ask you (or other people who testify) questions. CoverME.gov representatives can also submit documents and testimony. You can ask any agency witness questions too. The Administrative Hearings Officer will then make a decision. You will get a notice explaining the decision by US mail. It will also tell you what to do if you do not agree with it.

• This form is for consumers who wish to appeal an eligibility determination from CoverME.gov and have an administrative hearing on the matter.

• This form is for consumers who wish to withdrawal their appeal of an eligibility determination from CoverME.gov and not have an administrative hearing on the matter.

Visit our 1095-A FAQ page to learn more.

CoverME.gov is operated by the Maine Department of Health and Human Services

P.O. BOX 616 | AUGUSTA, ME 04332-6626 | 1-866-636-0355 | TTY: 711