How to Request a Medicaid Fair Hearing

If Medicaid denies your application, reduces your benefits, or terminates your coverage, you have the right to a fair hearing — a formal administrative hearing before a state-appointed judge. Fair hearings are a federally guaranteed right under 42 CFR § 431.220 and apply in every state's Medicaid program. Understanding how to request one, what to expect, and how to use the "aid continuing" provision can protect your coverage while you fight a denial.

What Is a Medicaid Fair Hearing?

A Medicaid fair hearing is a formal administrative proceeding where you (or your representative) present evidence to an administrative law judge or hearing officer explaining why Medicaid's decision to deny, reduce, or terminate your benefits was incorrect. The hearing is:

• Free of charge to you
• Held by your state Medicaid agency or a state administrative court
• Your legal right under federal Medicaid law — the state cannot deny you a hearing
• Often more effective than internal grievances because an independent decision-maker reviews the case

Fair hearings apply to all Medicaid programs: traditional fee-for-service Medicaid, Medicaid managed care plans, CHIP, and waiver programs (such as HCBS waivers for home and community-based services).

Grounds for Requesting a Fair Hearing

You can request a fair hearing when:

• Your Medicaid application was denied
• Your Medicaid coverage was terminated
• Your benefits were reduced (e.g., fewer home health hours, lower prescription coverage)
• Your provider was not approved
• A Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization for a service or medication was denied
• You were required to change managed care plans involuntarily
• Your Medicaid managed care plan denied a service through its internal process

For managed care plan denials specifically, most states require you to exhaust the plan's internal appeal before requesting a state fair hearing — check your state's specific rules.

The Filing Deadline: 90 Days (Sometimes Less)

Federal law requires states to allow at least 90 days from the date of the notice of adverse action to request a fair hearing. However, many states set shorter windows, and some actions have different deadlines. Examples:

• Federal minimum: 90 days from notice date
• Many states: 60 days from notice date
• Some actions (e.g., managed care plan internal appeal exhaustion): 120 days in some states

The notice you receive from Medicaid (called a "Notice of Adverse Action" or "Notice of Adverse Benefit Determination") must include your hearing rights and the deadline. Read this notice carefully and mark the deadline immediately.

Aid Continuing: Keep Your Benefits During the Appeal

One of the most powerful protections in the Medicaid fair hearing process is aid continuing. Under federal law (42 CFR § 431.230), if you:

1. Request a fair hearing before the effective date of the adverse action (termination or reduction), and
2. The request is based on the same issue as the adverse action

Then the state must continue your benefits at the prior level while the fair hearing is pending and a decision is made. This means if Medicaid is about to reduce your home health hours from 40 per week to 20, and you file your hearing request before the reduction takes effect, you continue to receive 40 hours until the hearing decision.

Critical: You must act before the adverse action takes effect. Read the effective date on your notice and file your hearing request immediately.

If you win the hearing: Your benefits are restored, and you owe nothing for the period of continued aid. If you lose the hearing: Medicaid may require you to repay the cost of services provided during the aid-continuing period. This is a risk to weigh, but for necessary medical services, it is often worth it.

How to Request a Fair Hearing

1. Locate the request information on your notice: The Notice of Adverse Action must include the address, phone number, or fax number for submitting a hearing request.

2. Submit your request in writing: Write a letter stating:

   • Your name, date of birth, Medicaid ID number, and address
   • A statement that you are requesting a Medicaid fair hearing
   • The specific decision you are appealing (cite the notice date and the action taken)
   • That you are requesting aid continuing if applicable (write: "I request that my benefits continue at the current level pending the outcome of this hearing")
   • Your reason for disagreeing with the decision (a sentence or two is enough at this stage — you will present full evidence at the hearing)

3. Send it via certified mail and keep a copy: Proof of timely filing is critical. Send to the Medicaid agency's hearing office, as listed on your notice.

4. Request legal assistance if available: Many states have legal aid organizations that provide free representation at Medicaid fair hearings. Contact your local legal aid society or go to lawhelp.org to find your state's resources.

What Happens at the Hearing

Fair hearings are typically conducted by telephone or videoconference (in-person hearings are less common post-COVID but may be requested). The hearing officer:

• Reviews the record (your case file from Medicaid)
• Hears your presentation of facts and arguments
• Hears the Medicaid agency's presentation
• Considers any documents or witnesses you submit

You may:

• Represent yourself or bring an attorney, advocate, or trusted person as your representative
• Submit documents (medical records, physician letters, plan documents)
• Call witnesses (including your physician)
• Review the Medicaid agency's file before the hearing — request this in writing as soon as your hearing is scheduled

The hearing officer must issue a written decision within 90 days of when you filed the hearing request.

After the Hearing Decision

• If you win: Medicaid must implement the decision and restore your benefits
• If you lose: You may seek judicial review in state court (the notice will explain your rights)
• If the decision is not issued within 90 days: This is a procedural violation — contact your state Medicaid agency's director and consider filing a complaint

Medicaid fair hearings have meaningful reversal rates. Your physician's documentation and your own clear explanation of why you need the service are the most persuasive evidence you can bring.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal