How to Appeal a Denial of Medicaid (Non-Eligibility)

Medicaid is a government program that provides free or low-cost health care coverage for people with limited resources. Although it's a federal benefit, each state manages its own Medicaid program, so the eligibility rules vary somewhat from state to state.

If you applied for Medicaid and your state Medicaid agency denied your application, you can appeal the denial. While your state agency will handle the appeal, it must follow federal Medicaid appeal rules.

Reasons for a Medicaid Denial for Non-Eligibility

Medicaid is a needs-based health care program. So, you can be denied Medicaid if you have too much income or too many assets. But there are other reasons you might have been denied Medicaid, such as the following:

• Your Medicaid application was incomplete or contained errors.
• You failed to provide information or documents requested by your state Medicaid agency in a timely manner (you missed a deadline).
• You applied for Medicaid based on disability and your state agency doesn't believe you're disabled.
• You don't meet Medicaid's citizenship or immigration status requirement.
• You have an income trust that's funded improperly.
• You transferred assets during Medicaid's five-year look-back period and are still in a penalty period.

(If you're 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.)

The Medicaid Denial Letter

When any state Medicaid agency rejects an application based on non-eligibility, it must issue a written denial notice.

When Will You Receive the Medicaid Denial Notice?

States have to obey federal deadlines for issuing decisions about Medicaid applications, and that means they 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 based on a disability, or
• 45 days from the date of your application if you apply for Medicaid on any other basis.

Your state must send you a written notice of its decision within those deadlines. (42 C.F.R. § 435.912(c)(3).)

What Does a Medicaid Denial Letter Include?

The denial letter must explain why you were denied Medicaid, including the specific rules your state agency used to deny your eligibility. The notice must also tell you about your appeal rights, including the following:

• that you have the right to a hearing to appeal the denial
• how to request a hearing
• how long you have to request an appeal, and
• that you have the right to represent yourself, hire an attorney, or have a spokesperson (like a friend or relative) help you.

Don't toss out your Medicaid denial letter. Read it carefully and hold on to it until your appeal is complete.

What to Do When Medicaid Is Denied

If your state has denied you Medicaid benefits, you have options. After receiving a denial notice, you can:

• ask your Medicaid caseworker to reverse the decision (if the denial was based on a mistake you made on your application or a missing document that you can now provide)
• reapply for Medicaid (if your situation has changed), or
• file an appeal (if you believe your state Medicaid office got something wrong).

If you're denied Medicaid because your income was too high or you had too many assets, you can apply again immediately if your situation has changed (perhaps you legally transferred some assets) and you now fall within your state's program limits. But be aware that your Medicaid eligibility date will change to reflect the new application date.

If you plan to request an appeal hearing (also called a "fair hearing"), you must do so before the deadline listed in your Medicaid denial letter, or you'll be required to justify a late appeal with a good reason. States have different deadlines. Some states give you only 30 days to appeal a Medicaid denial, but no state deadline can be more than 90 days from the date the denial notice is mailed.

How to Appeal a Medicaid Denial

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're 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 2/1/24."

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.

If you have Medicare and you receive a denial of a state cost-reduction program—Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualifying Individual (QI)—the appeals process works the same way. Learn more in our article on getting help with Medicare deductibles, premiums, and copays.

About Your Medicaid Appeal Hearing

You must appear for your appeal hearing (either in person or by phone, depending on your state's procedures) or risk having your appeal dismissed. If your appeal is dismissed because you missed the hearing, you'll need to show "good cause" (a justifiable reason for missing the hearing) to get the hearing reopened. And that can be difficult—saying you forgot the date or misplaced the notice, for instance, isn't considered good cause to miss your hearing.

The state Medicaid agency conducts the hearings in some states, while other states have separate hearings agencies or use their court systems for hearings. Your state Medicaid agency will send you information about how your hearing will be conducted.

Your hearing must be held at a reasonable time, date, and place, and you must receive adequate notice. How long your Medicaid appeal takes will vary, depending on factors like:

• how long you waited to file the appeal
• how many appeals are pending in your state, and
• whether or not you requested an expedited appeal.

Ordinarily, the state has to take final action on your appeal within 90 days—or within 7 days if you've been granted an expedited hearing. (42 C.F.R. § 431.244(f).)

One or more hearing officers (judges) could preside over your hearing. They should be impartial and not directly involved in the original decision to deny your benefits. Hearing officers might work for the state's Medicaid agency even if the hearing is at a separate agency.

How to Prepare for and Win a Medicaid Appeal

Before the hearing, federal Medicaid rules require states to allow Medicaid applicants to view their files. You have the right to review all the documents the state agency relied on to deny you Medicaid coverage. Take advantage of it.

It can be helpful to write down the points you want to make to the judge or hearing officer so you don't forget them during the hearing. You also have the right to have your own witness 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 might 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 you choose to help you with your appeal, or you can represent yourself.

When Does an Appeal Require a Medical Exam?

If your Medicaid application was denied because the state Medicaid agency thought you weren't disabled, the hearing officer might order another medical exam for you. If the hearing officer does that, you must attend the medical exam or you'll lose your appeal. The state will pay for any medical exams or tests that the hearing officer orders.

What to Expect After the Medicaid Hearing

You'll receive written notice of the hearing officer's decision. If you lose your hearing, the notice will tell you how to appeal again.

Depending on the state's particular procedures, at your next appeal, you might not get another chance to testify and bring witnesses (at what's known as an "evidentiary hearing"). Instead, you might be limited to submitting 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.

Getting Retroactive Medicaid Coverage

If you win your hearing and qualify for Medicaid, the state Medicaid agency will apply your Medicaid coverage retroactively back to the date you were first eligible. In most circumstances, that's the date you initially applied for Medicaid.

Keep track of any medical expenses that you have from the date of your Medicaid application until your benefits are approved. Then, notify the state Medicaid agency of those expenses once you qualify for benefits.

_{Updated March 8, 2024}