Requesting a Medicaid Hearing

The notice must also provide instructions on how to appeal the decision made by the Medicaid agency. In some states, the first step in the Medicaid appeal process is an administrative hearing, commonly known as a "fair hearing." Other states, however, provide for a local "evidentiary hearing," which may then be appealed through the fair hearing process. The notice should tell you how to request a hearing.

You may request a hearing whenever either your application for Medicaid has been denied or your existing Medicaid benefits have been reduced or terminated, and you believe the state Medicaid agency is mistaken in its analysis. You may also be able to request a hearing to dispute other aspects of the decision, such as a decision about how much you must contribute to the cost of your care or the amount of your benefit. The request for a hearing should be filed promptly since there is always a deadline for making such a request. In addition, when existing Medicaid benefits are improperly decreased or terminated, you may want to request that your benefits continue during the appeal process. Such a request, often referred to as a request for "aid paid pending appeal," must be made within 10 days of the date on the denial or termination/reduction notice. As a cautionary note, however, you may be asked to repay these continued payments if you ultimately lose the appeal.

States may require hearing requests to be in writing, although some states permit requests to be made orally. Employees of the state Medicaid agency often are willing to discuss the issues after an appeal has been filed. Sometimes a supervisor will get involved and resolve the situation, eliminating the need for any type of hearing. If you are concerned about the deadline, however, you may want to file your request in writing and retain proof of the date of your request. If the state loses your request, you may lose your rights unless you can prove you filed your hearing request on time.

In some states, managed care organizations, rather than the state Medicaid agency, make decisions as to whether a particular health care service or medical device will be covered by Medicaid. States which have a Medicaid managed care component sometimes require enrollees to file an appeal through the managed care organization prior to filing a request for a fair hearing. Other states provide individuals with the option of filing an appeal through the managed care organization or the Medicaid fair hearing system.