Being Denied Medicaid Eligibility and Challenging the Decision via a Medicaid Fair Hearing

Last updated: September 02, 2024

 

Introduction

After receiving a Medicaid application, a state’s Medicaid agency must determine one’s eligibility within 45 days (90 days for applications based on disability). An applicant is notified of Medicaid’s decision via a written notice of determination. If one is eligible, they receive a Medicaid Approval Notice informing them of their eligibility. If they are not, they receive a Medicaid Denial Notice, stating that they are not Medicaid-eligible and why.

While the reasons for Medicaid denial vary, the most common reasons include submitting an incomplete application, required documentation was not provided, the applicant was over Medicaid’s financial eligibility criteria (income and / or assets), the functional need for long-term care was not met, and Medicaid’s Look-Back Period was violated. Additionally, applications are sometimes denied due to a mistake made by a caseworker. More on Reasons for Medicaid Denial and Becoming Medicaid-Eligible.

If a Medicaid applicant does not agree with Medicaid’s decision of denial, they have the right to appeal (challenge) the decision through a free process called a Medicaid Fair Hearing. This hearing allows the opportunity for the Medicaid decision to be reconsidered by a neutral party and potentially changed. One’s state Medicaid agency generally has up to 90 days after receiving a request for a fair hearing to have the hearing and make a decision.

While Medicaid applicants (and beneficiaries) can appeal for any action made by one’s state Medicaid agency that impacts their eligibility, services, or benefits, this article focuses on the appeal process for Medicaid denials. The process for requesting a fair hearing (including the timeframe to do so) for other reasons may differ from the information contained in this article.

 

Types of Medicaid Denials

Generally, there are three “types of Medicaid denials”. While not formal designations, they can be instrumental in illustrating that an applicant is sometimes denied Medicaid, and rightfully so, and other times, they are denied, when actually eligible. This information can assist one in deciding if appealing a Medicaid Denial Notice is right for them.

1) Denied incorrectly because of an error made by the applicant – applicants make unintentional errors with frequency when applying for Medicaid. The paperwork is confusing, and the documentation requests are overwhelming. In this situation, a denied applicant might contact the Medicaid caseworker and request a reversal. Resolving an incorrect denial in this manner is much more simple and quicker than appealing the Medicaid decision.

2) Denied incorrectly because of an error made by the caseworker – nobody is perfect and that includes Medicaid caseworkers charged with reviewing applications. By some estimates, as much as 25% of all Medicaid denials are made in error. A mistake could encompass miscalculating income and / or assets or losing a required document. Furthermore, Medicaid’s rules, which are often state-specific, are complicated and tend to change. A caseworker could make an “error” in interpreting these rules. While an applicant can request a reversal, one might need to file an appeal.

3) Denied and correct to be denied – Even those applicants who have been correctly denied Medicaid can take steps to gain eligibility and reapply for Medicaid. For instance, there are Medicaid planning strategies available to help lower one’s countable income and assets and meet Medicaid’s financial eligibility criteria.

It is highly recommended that Medicaid applicants denied Medicaid eligibility reach out to an Experienced Medicaid Planner. These professionals have a vast amount of experience in appealing and overturning Medicaid denials. They know the legalities of Medicaid, including state-specific rules, and can assist one in winning their fair hearing. Furthermore, if there is any question as to if one was incorrectly denied Medicaid eligibility, Medicaid Planners can assist in making this determination. Find a Professional Medicaid Planner.

 

The Medicaid Denial Notice

A Medicaid Denial Notice contains crucial information and it is vital that one read it very carefully. The Medicaid agency is required to include the following information:

1) The reason the applicant was denied Medicaid coverage, along with the specific policy and / or rule(s) referencing the reason for denial.
2) The applicant’s right to appeal (challenge) the denial through a process called a fair hearing.
3) Directions on how to file an appeal (request a fair hearing) and the deadline for doing so.
4) The applicant’s right to represent themself in the fair hearing or have a friend, relative, attorney, Medicaid Planner or someone else, do so.

 

The Medicaid Fair Hearing

A Medicaid Fair Hearing is a recorded administrative process that allows a Medicaid applicant / beneficiary to challenge a decision made by their state’s Medicaid agency. During the hearing, a hearing officer, also called an administrative law judge, listens to both sides of the case and makes a decision based upon the evidence and facts presented. How hearings are held are state-specific, but may be in-person, over the phone, or by videoconference.

Specific to a Medicaid denial, a representative from the Medicaid agency will explain why the applicant was denied eligibility and provide records and documentation as to how that decision was made. The applicant can explain why they disagree with Medicaid’s decision and provide evidence in support of their eligibility. Examples of supportive documentation might include bank statements, a statement from their physician, medical records, and communication (i.e., emails) between the applicant and their caseworker. Both sides can bring witnesses to testify, with the opposing side given the opportunity to cross-examine the witness. As mentioned previously, the applicant has the right to have someone else, such as a Professional Medicaid Planner, represent them.

Generally, the hearing officer does not make their decision the day of the hearing. Instead, a written notice is mailed to the applicant at a later date.

While Medicaid Fair Hearings can be managed by a state’s Medicaid agency, it is required that the hearing officer be impartial (neutral). It is prohibited that they be directly involved in the decision being appealed. In some states, fair hearings are conducted by outside hearing agencies. As an example, in Georgia, the Office of State Administrative Hearings (OSAH) conducts the hearings.

Generally, within 90 days of requesting a Medicaid Fair Hearing, one should have gone through the entire appeal process and received a decision about their Medicaid denial. If one has an urgent medical need, the process can be expedited, or in other words, rushed.

 

Requesting a Medicaid Fair Hearing

It is vital that one appeal (request a hearing) Medicaid’s decision of denial prior to the deadline set by their state’s Medicaid agency. The deadline, which is generally between 30 and 90 days from the date of one’s Medicaid Denial Notice or the date of the letter’s postmark, is included on one’s Medicaid Denial Notice. As an example, the following states allow the following number of days to request a hearing: Arizona (30), Georgia (30), Kansas (33), Illinois (60), New York (60), California (90), Nevada (90), Oregon (90), and Florida (90). To avoid any potential of missing the deadline, one should request a Medicaid Fair Hearing as quickly as possible.

Included in one’s Denial Notice is information on one how to request a hearing. Depending on the state, this request may be made online, by phone, mail, email, fax, or in-person. It is highly recommended that one submit a hearing request in writing and get proof that the request was made prior to the deadline. For instance, one can send the appeal via certified mail or submit it in-person and ask for a date stamped copy of the request.

Some states have a state-specific Medicaid Hearing Request form. This includes Idaho (Fair Hearing Rights and Request Form) and Nevada (Fair Hearing Request Form). Other states will simply request that certain information be provided. Generally speaking, this includes one’s statement that they are requesting a fair hearing, the reason why (i.e., denied Medicaid eligibility), and why they disagree with Medicaid’s decision. They should also include their name, mailing address, phone number, email address (if applicable), case number or Social Security number, and signature. It is recommended that a copy of the Medicaid Denial Notice be submitted with the request for a hearing.

Following a request for a hearing, one will receive a Notice of Hearing (generally by mail) indicating the date, time, and location of the hearing. Other instructions regarding the hearing will be included. For instance, if the hearing is taking place by conference call, it will include the phone number to call and an access code. How quickly the hearing is scheduled tends to be state-specific. For example, in New York, hearings are generally scheduled three to four weeks after the request is made, Kansas will generally schedule them within one or two months of the request, and Alaska requires a response within 10 days.

It is important that one does not miss their scheduled hearing. Doing so generally results in one’s appeal being dismissed.

 

Expedited Hearings

Yes, one can request an Expedited Medicaid Fair Hearing, or in other words, a “faster” fair hearing, if there is an urgent medical need that put’s their life, health, or ability to keep, maintain, or regain their full functioning, at risk. This is a much faster process than a Standard Appeal, which allows a Medicaid agency 90 days to go through the appeal process (from receiving the hearing request to making a decision). In fact, an expedited hearing is scheduled as quickly as possible.

Requirements for requesting an expedited hearing, and how to do so, are included in one’s Medicaid Denial Notice. One may be required to send medical records and / or a signed statement from their physician with their request, and upon review, the request for a “faster” hearing will either be approved or denied. If the request is approved, the hearing will be scheduled right away. If denied, the request will be treated as a Standard Appeal.

 

Before the Medicaid Fair Hearing

To help one prepare for their hearing, the Medicaid applicant has the right to review their Medicaid file, including any documents and information that the Medicaid agency will present to the hearing officer in support of their decision to deny eligibility. In some states, the Medicaid agency might automatically send this information, and in other states, one will need to request it. In addition to reviewing their Medicaid file, denied applicants should gather supporting evidence of their eligibility for Medicaid. For instance, if one was denied Medicaid-funded long-term services and supports due to not meeting the state’s functional need criteria, such as a Nursing Facility Level of Care, one might obtain a copy of their medical records and a statement from their physician explaining why assistance is medically necessary. Furthermore, the applicant can bring witnesses to the hearing who can support their need for long-term care.

Some states attempt to resolve the dispute prior to a Medicaid Fair Hearing by reviewing the case. This “review” is generally optional and can be waived. In the following states, it goes by the following names: Arizona (Pre-Meeting Hearing), Montana (Administrative Review), Nevada (Hearing Preparation Meeting), New York (Pre-Hearing Conference). In South Carolina, an Eligibility Respondent Coordinator (ECR) reviews the request for an appeal and the Medicaid determination. By reviewing the case and sometimes resolving the issue, there is not always a need to move forward with a hearing.

 

The Medicaid Fair Hearing Decision

One generally is notified of the hearing officer’s decision via a written notice. How long this takes varies based on the state, but as mentioned previously, one must receive their hearing decision within 90 days of requesting an appeal. In New York and Kansas, the decision must be made within 30 days of the date of one’s Medicaid fair hearing.

If one wins their appeal for a Medicaid denial, they will immediately be enrolled in Medicaid and retroactively eligible back to the date they applied for Medicaid. This means that Medicaid will cover incurred medical expenses between one’s application date and winning their Medicaid Fair Hearing. Therefore, one should keep track of any medical expenses between submitting a Medicaid application through receiving an appeal decision.

If one loses their Medicaid Fair Hearing, they can further appeal. Information on how to do this will be in the Notice of Decision.

In some cases, further action may need to be taken before the hearing officer can make a decision. For instance, if one was denied Medicaid due to functional need not being met, the hearing officer may require one to undergo another medical exam.

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