Medicaid fair hearing: how to challenge a denial or termination

When a fair hearing is required

States must offer a fair hearing whenever an applicant is denied or not acted upon with reasonable promptness, or whenever a beneficiary's eligibility, services, or claims are denied, reduced, or terminated.

Source: 42 CFR 431.220. See https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-431/subpart-E/section-431.220.

Deadlines

States must allow a reasonable time to request a hearing — at least 90 days from the date the notice of action was mailed (42 CFR 431.221).

Standard hearings must be decided and effectuated within 90 days of the request; expedited Medicaid managed care appeals within 3 working days when delay would jeopardize life, health, or ability to regain function.

Aid paid pending

If you request the hearing before the effective date of an action that reduces or terminates benefits, the state generally must continue benefits during the appeal — known as aid paid pending. See 42 CFR 431.230.

If you lose the hearing, the state may try to recoup benefits paid during the appeal. Weigh that risk before requesting continued benefits.

Managed care: internal appeal first

Medicaid managed care enrollees must exhaust the plan's internal appeal before requesting a state fair hearing (42 CFR 438.402(c)(1)(i)). The plan has 30 days for standard appeals, 72 hours for expedited.