Coverage type · Medicaid or children's coverage
Children's Health Insurance Program
Low-cost coverage for children run by your state. A separate program uses an independent external review, not a Medicaid fair hearing. For a managed care plan, the plan appeal comes first, within 60 days.
On this page 7
- Who has this
- Children covered by their state's Children's Health Insurance Program, and the parents or guardians who act for them.
- Who regulates it
- Your state, under the federal rules for separate programs in Title 42 of the Code of Federal Regulations, Part 457, Subpart K. The state either uses a program-specific review process or follows the state's standard review for all health insurers.
- Can your state help?
- Yes. States run these programs, choose the review process and name it. Your state page lists your state's agency, and legal aid programs where the state's data names them. Find your state.
How to tell this is your coverage
- The notice about your child's denial, delay, reduction or ending of care or enrollment explains a right to review, the standard and fast timeframes, how to ask for review, and when enrollment and benefits may continue.
- If you are not sure whether your child's coverage is a separate program or part of Medicaid, read your notice for the review steps it names, or ask your state.
- If your child is enrolled in a managed care plan, the plan sends the notice and the plan appeal comes first.
The appeal steps, in order
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First review by the plan or program
Official name: Internal review (plan appeal, where there is one)
- Who decides
- Your child's managed care plan, or the state program if it runs its own internal review
- Your deadline
- For a managed care plan, 60 calendar days to file the plan appeal (the Medicaid managed care rule it follows counts from the date on the notice). For other separate programs the rules we use set no single number, so use the date on your notice. Check the date on your notice, which controls.
- Their deadline
- For a managed care plan, 30 calendar days for a standard appeal and 72 hours for an expedited appeal, as in Medicaid managed care. For a health services review overall, the whole review must be completed within 90 calendar days of the request, and an expedited review within 72 hours.
- What to send
- A request as your notice describes (an oral request is allowed for a managed care plan appeal). Say which decision you dispute and why. Add your child's records and your doctor's letter.
- If you lose, or hear nothing
- If the plan or program upholds its decision, ask for an independent external review.
- The rule
- 42 CFR 457.1260, managed care appeals and external review
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Independent external review
Official name: External review
- Who decides
- The state, or a contractor other than the one responsible for the decision
- Your deadline
- After a managed care plan appeal, the review must be available for no less than 90 and no more than 120 calendar days from the plan's decision. For other separate programs, the date is on your notice. Check the date on your notice, which controls.
- Their deadline
- External review must be completed within 90 calendar days of the request for internal review (if any) or external review, covering both levels. If a physician or the plan decides the standard time could seriously jeopardize life, health or function, an expedited review is due within 72 hours (72 hours for each level if both exist).
- What to send
- A request as your notice describes. Include the decision you are disputing, your child's records and your doctor's letter.
- If you lose, or hear nothing
- This is the last review the federal rules require. Ask your state and free legal aid what else is available.
- The rule
- 42 CFR 457.1150, external review
If waiting could harm your health
Ask for an expedited review when waiting could seriously jeopardize your child's life, health or ability to function. Either the physician or the plan can make that finding. The review is then due within 72 hours. Federal rules require coverage to continue during review only when the issue is suspending or ending enrollment, or failing to decide eligibility in time. They do not require a particular service to continue while you dispute a denial or reduction. For a prior authorization request from 1 January 2026, the decision is due within 7 calendar days (72 hours if expedited), with a possible extension of up to 14 days. This does not cover drugs. Check the date on your notice, which controls.
Free help for this coverage
- Your state's program and review office
Your notice says how to ask for review. Your state page names the agency and where the state's data gives them, its hearing page and deadline.
- Legal aid
Free civil legal help for people with low incomes. Some programs advise on children's coverage denials, but none can take every case. Your state page lists legal aid programs where the state's data names them.
Who this covers
This page is for children whose coverage is a separate Children’s Health Insurance Program run by the state, and for the parents or guardians who act for them. Read the Children’s Health Insurance Program appeals guide. If the notice says your child’s coverage is part of Medicaid, see Medicaid or Medicaid managed care.
How to tell this is your coverage
Look at the notice. Matters that must be reviewable include denial of eligibility, failure to decide eligibility in time, suspension or ending of enrollment (including for unpaid cost sharing), and delay, denial, reduction, suspension or ending of health services, or failure to approve, furnish or pay for them in time. Notices must be timely and in writing, with the reasons.
A state must use either a program-specific review process that meets the federal rules above, or a statewide standard review that follows the state’s rules for all health insurers. That is why the name and steps differ by state. Find your state: find your state.
What does not apply to you
For a separate program, the review is not a Medicaid fair hearing. The rules above apply to health services reviews, and after a managed care plan appeal the next step is a state external review, not a fair hearing. The standard reading is that children covered through a Medicaid expansion follow the Medicaid rules, but we could not confirm this in the regulation text. Read your notice, which should state which review applies.
Where people go wrong
- Treating this program like Medicaid. Separate programs use external review instead of a fair hearing, and federal rules do not require a disputed service to continue during review.
- Waiting after the plan says no. If your child is in a managed care plan, the plan appeal has 60 days, and the external review window opens after the plan’s decision. Use the date on your notice.
- Not asking in time for a fast review. An expedited review is due within 72 hours, but it applies only if the physician or the plan decides the standard time could seriously jeopardize life, health or function.
Free help is listed above.
Sources
- 42 CFR 457.1120, state plan requirement for a review process
- 42 CFR 457.1130, program specific review process
- 42 CFR 457.1150, external review
- 42 CFR 457.1160, program specific review timeframes
- 42 CFR 457.1170, continued enrollment
- 42 CFR 457.1180, notice
- 42 CFR 457.1260, managed care appeals
- 42 CFR 457.495, prior authorization decision timeframes