Medicaid (fee-for-service)

Who this covers

This page is for people on Medicaid whose state pays their providers directly (fee-for-service). If you are enrolled in a Medicaid managed care plan, see Medicaid managed care. If the person is a child in the Children’s Health Insurance Program, see the Children’s Health Insurance Program. Read the Medicaid fair hearing guide or use the Medicaid hearing planner.

How to tell this is your coverage

The state must tell you in writing, at application and whenever it denies eligibility, benefits or services or takes another adverse action, that you have a right to a fair hearing, how to ask, and the deadlines. The notice must give the specific reasons and rules. If it does not, ask the agency for them in writing and still file inside the deadline.

State-by-state fair hearing deadlines are not collected on this page. The deadline is on your notice; it varies by state. Find your state to see what the state’s data says: find your state.

What does not apply to you

You do not have a plan appeal first. In fee-for-service Medicaid, the fair hearing is the appeal. The managed care plan appeal steps and their 60-day and 90-to-120-day clocks apply only if you are in a managed care plan. Medicare appeal levels and forms do not apply to a Medicaid decision.

If you also have Medicare, Medicare decisions are appealed through Medicare. Prior authorization deadlines in fee-for-service Medicaid: from 1 January 2026 the state agency must decide a standard request within 7 calendar days (extendable by up to 14 calendar days) and an expedited request within 72 hours, unless state law sets a shorter time. This does not cover drugs.

Where people go wrong

• Counting “90 days” as your deadline. Ninety days is the federal upper limit, not a promise. Your state may set a shorter time, so use the date on your notice.
• Assuming services continue automatically. Services continue only if you ask for the hearing before the date the action takes effect, or in the narrow cases of the 10-day reinstatement rule above. If you lose, the state may recover the cost of services provided only because benefits continued.
• Accepting “not a covered benefit” for a young person. For people under 21, the state must provide any service that federal Medicaid law allows and that is medically necessary to correct or ameliorate conditions found by screening, whether or not the state plan covers the service. This is called Early and Periodic Screening, Diagnostic and Treatment. The state decides medical necessity case by case. Whether a hard visit limit can be challenged this way is a common legal reading we could not confirm in federal guidance, so ask free legal aid.
• Overlooking new work requirement notices. Under section 71119 of Public Law 119-21, states must, for coverage on or after 1 January 2027 (earlier at state option), require certain adults aged 19 to 64 in the Medicaid expansion group to show 80 hours a month of work or other qualifying activity. If the state cannot verify compliance it must send a notice and allow 30 calendar days to respond before denying or ending coverage. The fair hearing rules above apply to eligibility decisions. How the new rule works with hearing and continuation rights is not confirmed, so ask legal aid.

Free help is listed above.