If you are a Medicaid recipient and your state Medicaid agency or managed care organization will not approve payment for a medical treatment, then you have the right to appeal the denial. Every state’s Medicaid program is different, but each state is required to follow certain federal Medicaid rules, including those about fair hearings for Medicaid recipients who are denied services. (If you were applying for Medicaid coverage for the first time and were denied, see Nolo's article on appealing a denial of Medicaid for ineligibility.)
Your state Medicaid agency must give you a written notice, known as a notice of action, when it denies a service or treatment that you or your doctor requested. The written notice must describe what action the agency is going to take and give the reasons for the action; it must cite the specific rules that the agency is relying on; and it must contain information about how to appeal and about the deadline for appealing. Except in a few unusual situations, federal rules require that your Medicaid agency mail denial notices at least 10 days before taking action. Look at your notice carefully, and keep it until your appeal is completely over. There should be information in your notice that will help you appeal.
The appeal deadline is one of the most important pieces of information on your appeal notice. You must request your appeal within the deadline, or you will be required to justify a late appeal with a good reason. States have different deadlines, but the deadline will be no more than 90 days from the date the denial notice was mailed (and may be less).
Some states require that Medicaid recipients make their requests to appeal in writing, and some states allow you to request an appeal orally. Even if you are not required to make a written request to appeal, it is a good idea to write a simple appeal notice like “I want to appeal the denial notice dated 8/1/12.” Sign and date your appeal notice. If possible, submit it in person to your local state Medicaid agency office, and get the person who takes your appeal notice to make you a copy of it and put a date stamp on it to show that it was received by the deadline. You want to avoid having to prove later that you submitted your appeal on time or having to justify a late appeal.
In order to continue to receive benefits, you may only have 10 days to file the appeal (see below).
If you get your notice from a managed care organization, it may have information about filing a grievance with the organization. You can file a grievance and try to win your case using the organization’s own internal process, but you should also file an appeal with your state Medicaid agency before your appeal deadline runs out. If you are unsuccessful in your grievance with the managed care organization, you want to preserve your right to appeal.
You should look carefully at your notice to see if you are entitled to “aid paid pending.” This means a continuation of your benefits pending the outcome of your appeal. If you were denied a new service or treatment, the benefit won't be paid for until you win your appeal. For instance, a recipient who gets a notice that Medicaid will not pay for his gastric bypass surgery will not be entitled to aid paid pending and will need to win his appeal before he can get the surgery.
But in general, if you are receiving a Medicaid benefit and you get a notice telling you that it will be reduced or cut off, you are probably entitled to have the current benefit continue for as long as the appeal process takes. For example, a recipient who gets a notice that he will lose his Medicaid because the agency thinks he is "over-income" (is earning too much money) is entitled to request that the "aid" be "paid" pending the outcome of his appeal.
Federal Medicaid guidelines require Medicaid recipients who want aid paid pending to request a hearing before the date that the agency intends to take action. That means you will need to submit your appeal notice quickly, because the agency may have only mailed you a notice 10 days before it intends to take the adverse action. If you are entitled to aid paid pending, your notice should state what your deadline is to request the aid paid pending.
If you received aid paid pending but you lose your appeal, the Medicaid agency is allowed to try to get you to repay the amount of money that it cost to provide you benefits during the aid paid pending period. Keep in mind that the cost of providing Medicaid benefits is not just the cost of medical services you receive during a certain period, but also the monthly premium cost to the state to keep you enrolled in the program.
Many Medicaid appeals are settled in the pre-hearing stage, so you may not have to go to a hearing to win your appeal. After you submit your appeal request, an agency representative may contact you to find out the reason for your appeal. If settlement is possible, the representative will discuss that with you.
If your Medicaid appeal goes forward to an administrative hearing, the state Medicaid agency will give you information about how the hearing will be conducted. Federal Medicaid rules require states to permit Medicaid recipients to review their files and to review all of the documents that the agency has relied on before the hearing. You may find that it is helpful to write down the main points you want to make to the judge or hearing officer so that you don’t forget them during the hearing. You also have the right to have your own witnesses testify at the hearing and the right to cross-examine any of the agency’s witnesses. If an issue comes up during the hearing that you think would be resolved if you could submit some additional evidence to the judge, ask the judge to give you more time to get the information before making a decision.
You can represent yourself at a Medicaid hearing, but you may want to find an attorney to represent you. While most Medicaid denial hearings have relaxed rules of evidence, the hearing is still a legal hearing with witnesses testifying and cross-examinations. You can contact your local legal aid office to find out if a lawyer is available to represent you in a Medicaid appeal. Federal Medicaid rules also allow you to use a relative, friend, or any other spokesperson that you choose to help you with your appeal, but your chance of winning increase if you hire a Medicaid lawyer.