Fair Hearings and Appeals: What Happens If You're Denied?

If you have applied for Medicaid (or for a change in benefits) for yourself or on behalf of a family member and received a denial, you have the right to appeal. A Medicaid lawyer can help if your application is denied or is not handled in a timely manner, or if there is a dispute over benefit amounts, payments, or other problems. Having an experienced lawyer representing you can give you peace of mind in knowing the process will be handled competently.

The Medicaid lawyers at Pierro, Connor & Strauss, LLC are here to assist with applications, appeals, and related issues like the amount of hours awarded in a Community Medicaid case.

The Medicaid Denial Process

Your application could be denied for countless reasons. No matter what the alleged cause, the Medicaid program is required, under federal law, to inform you of its decision, and the reasons for it, in writing, and to provide a method to appeal the decision.

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Not only can you appeal the decision to deny your application, but you can raise complaints about procedure. For example, if the denial letter does not explain the reason for the denial with enough information so that you can understand it, you may have an additional ground for appeal. Since Medicaid programs are run by the states but subject to federal laws, the possible reasons for your appeal and the procedures you must follow may fall under either state or federal laws. This makes the appeal process complex, but our Medicaid lawyers have a thorough understanding of the appeals process.

How to Appeal a Medicaid Denial

Your options to appeal your Medicaid decision will be affected by both state and federal law. If your application is denied, the applicant always has the right to a fair hearing. However, before a fair hearing is needed, the applicant also may have the ability to request an informal meeting. An informal meeting typically occurs with a person who has the authority to make decisions at the local Medicaid office, and if the issue which caused the denial is remedied, then a further appeal isn’t needed. If informal means do not resolve the issue at dispute, a fair hearing then can occur which takes place before an administrative law judge.

State rules determine how you must request the appeal. For example, in New York, you have the right to an informal conference as well as to a fair hearing. You have 60 days to file an appeal, and it may be done by mail, phone, or fax.

What happens in an Informal Conference?

When they are available, informal conferences are, not surprisingly, much less formal than fair hearings. In an informal review, you have the chance to sit down with a representative of the state agency who has the authority to make decisions about your request. It is an opportunity to address the reasons stated in your denial letter – you can provide information that was missing, or explain why you believe the decision was incorrect. If the reviewer agrees with you, they will change your eligibility determination and you do not need to take further action. If they do not agree with you, you will still have the opportunity to request a fair hearing.

What Happens in a Medicaid Fair Hearing?

A fair hearing is a bit like a trial in court. Both you and a Medicaid representative appear before an impartial administrative law judge. Both sides are permitted to present evidence, make arguments and even call witnesses. You will argue why your request should have been approved, while the Medicaid representative will argue that your denial was proper. You have the right to have an attorney to advocate for you.

What Happens after an Unsuccessful Medicaid Hearing?

If you do not prevail at the fair hearing, you still have the right to appeal through the local courts. Each state has its own rules on which courts have jurisdiction; in some cases, you may even want to file in federal court.

A Medicaid lawsuit is more involved than an administrative hearing. It is important to speak with an attorney to determine the strength of your case, whether you should file the appeal, and the deadlines for filing. If you decide to file an appeal in court, it is important to file your appeal quickly because you can be liable for medical costs that accrue from the time of the hearing until you file a new application.

Get help from a skilled Medicaid appeals lawyer

Pierro, Connor & Strauss, LLC provides legal services to clients in ten locations that include the Capital Region, New York City, Long Island (Ronkonkoma, Garden City, Westchester, Hudson, Utica and Lake Placid. We also serve clients in Clark, NJ, Falmouth, MA, Clearwater, FL and in Connecticut.

Our attorneys review Medicaid applications and Medicaid decisions to determine the merits of an appeal. When appropriate, we file appeals and provide strong representation at hearings. Call today to schedule a consultation to discuss your situation.

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What Happens If Your Medicaid Application Is Denied in New York?