If you applied for Medicaid and your state Medicaid agency denied your application, then you can appeal the denial. While your state agency will handle the appeal, it must follow federal Medicaid appeal rules.
You might be denied Medicaid because you have too much income or assets or, if you applied for Medicaid on the basis of disability, because your state Medicaid agency did not believe you were disabled. (If you are a current Medicaid recipient who was denied coverage of a particular service or treatment, read our article on when Medicaid denies a service or treatment.)
When a state Medicaid agency rejects an application for benefits, it must issue a written denial notice.
When you'll receive the notice. States have to obey federal deadlines about issuing decisions about Medicaid applications. States have the following amount of time to send you a denial notice:
90 days from the date of your application if you apply for Medicaid on the basis of a disability
You should receive a written notice of decision within those deadlines.
What the notice will include. The notice must tell you that you have the right to a hearing to appeal the denial, how to request a hearing, and that you have the right to represent yourself, hire an attorney, or have a spokesperson (like a friend or relative) help you. The notice must also give the reasons for denying your application and the notice must include the specific rules your state Medicaid agency is using to deny you eligibility.
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. States have different deadlines, but all are required to be no more than 90 days from the date that the denial notice is mailed.
Don't toss out the denial notice; read it carefully and hold on to it until your appeal is complete.
Some states require that Medicaid recipients make their requests to appeal in writing, and some don't. Read your notice carefully to learn your state's rules. But even if you are not required to file a written notice, you should. You can write a simple appeal request like “I want to appeal the denial notice dated 8/1/12.” If possible, submit your request in person at your local state Medicaid agency office, and have it date stamped 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.
Once your appeal is set for a hearing, you must appear for the hearing (either in person or by phone, depending on the state’s procedures) or risk dismissal of your appeal. If your appeal is dismissed because you missed the hearing, you will need to show “good cause” (a justifiable reason for missing the hearing) to get the hearing reopened. It can be difficult to show that you had good cause; it is not enough to say that you forgot the date or misplaced the notice.
Your state Medicaid agency will send you information about how the hearing will be conducted. In some states, the state Medicaid agency conducts the hearings, while other states have separate hearings agencies or use their court systems for hearings. Hearings must be conducted at a reasonable time, date, and place, after adequate notice. Hearings can be conducted by one or more hearing officers (judges), as long as those individuals are impartial and were not directly involved in the original decision to deny your benefits. Hearing officers can work for the state’s Medicaid agency even if the hearing is at a separate agency.
Before the hearing, federal Medicaid rules require states to allow Medicaid applicants to view their files and to review all of the documents that the agency has relied on to deny you Medicaid coverage.
It can be helpful to write down the 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 ask any of the agency’s witnesses questions.
If something arises during the hearing (such as a medical question) that you think could 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 may want to find an attorney to represent you. You can contact your local legal aid office to find out if they represent clients in Medicaid appeals, or contact a lawyer. Federal Medicaid rules also allow you to use a relative, friend, or any other spokesperson that you choose to help you with your appeal, or you can represent yourself.
If your Medicaid application was denied because the state Medicaid agency thought you were not disabled, the hearing officer may decide to order another medical exam for you. If the hearing officer does that, you must submit to the medical exam or you will lose your appeal. The state will pay for any medical exams or tests that it orders.
You will receive written notice of the hearing officer’s decision. If you lose your hearing, the notice will tell you how to appeal. Depending on the state’s particular procedures, at your next appeal, you may not get another chance to testify and bring witnesses (at what's known as an evidentiary hearing). Instead, you may have an appeal in which you are limited to making written arguments about evidence that came out at the first appeal hearing. Check your denial notice carefully to find out what the appeal processes are in your state.
If you win your hearing and qualify for Medicaid, the state Medicaid agency will apply your Medicaid coverage retroactive to the date that you became eligible. In most circumstances, that will be the date that you filed an application for Medicaid. Keep track of any medical expenses that you incur from the date of your Medicaid application so that you can notify the state Medicaid agency of those expenses when you qualify for benefits.