What a Medicaid fair hearing is like

If you have asked for a Medicaid fair hearing, or are thinking about it, the word “hearing” may sound like a courtroom. It is usually closer to a structured meeting. This page explains what it tends to be like, so you can plan. The rules for asking are in Medicaid appeals and fair hearings and, for plan decisions, Medicaid managed care.

Hearings vary by state. Look at your notice and your state page on the state pages for how yours is held.

Texas example. In Texas, the state’s Health and Human Services Commission runs the hearing. You can ask for one in writing, by calling 2-1-1, or at a local Health and Human Services office. Hearings are usually held by conference call. The deadline is 90 days from the date of the case action on your Notice of Case Action, or 120 days for an action by a Medicaid health plan, counted from the plan’s final decision. Late requests are reviewed for good cause. These details come from the Texas state record on this site. Confirm them on your notice.

Vermont example. The best plain description this site found comes from Vermont’s Office of the Health Care Advocate, part of Vermont Legal Aid. The details below that mention Vermont are one state’s example. Your state may use a different agency, different forms and a different format.

What this means

A fair hearing is the state’s own review of a decision it made, or that its Medicaid plan made. You explain why the decision was wrong, show your evidence, and the person or board running the hearing decides. (Vermont example: the Human Services Board decides.)

The federal rules require the state to run a hearing system that meets the due process standards of the Supreme Court’s decision in Goldberg v. Kelly. The state must tell you about the hearing in writing, including how to ask, your right to be represented, and the deadlines.

What to do

1. Ask for the hearing on time (you). Your notice gives the deadline and where to send the request. Mail it early and keep proof. (Vermont example: advocates there suggest mailing about two weeks ahead of the deadline.)
2. Ask for continued benefits if the notice allows (you). If you ask for the hearing before the date the change takes effect, the state may not stop or reduce your services until the decision, unless the only issue is a federal or state law or policy. If you lose, the state may ask you to repay the cost of the services it kept going.
3. Ask who will be there and how it will be held (you). In Texas, hearings are usually held by conference call, and Vermont’s guide also describes a conference held by phone. Other states may hold hearings in person or by video. Ask the hearing office, and say if you need an interpreter.
4. Write down who you talk to (you). Note the date, name and what was said every time you speak to the agency.
5. Collect your evidence (you and your doctor). The notice, your medical records, and a letter from your doctor saying why you need the service. Vermont’s guide, one state’s example, says where to send copies of your evidence before the hearing, so ask your hearing office where yours go.
6. Decide whether to have help (you). You have the right to be represented. Your notice says how to name someone to represent you. A lawyer or an advocate is one option, and free legal help is listed on the legal aid page.
7. Write a short outline (you). Vermont’s guide, one state’s example, offers a checklist of what to say, in order. Say what the decision was, what you want, and the facts that show the decision was wrong.

On the day

You may hear the state’s side first. The agency may be represented by its own lawyer. Vermont’s guide, one state’s example, tells readers not to let that worry them, because they can still win. Present your outline, and describe what you need in plain words. If something is unclear, ask the person running the hearing to repeat it.

Keep your answers short and specific. Say what the service is for and what happens without it. If you do not remember a date, say so and say where the paper is.

After the hearing

The state must ordinarily take final action within 90 days of your request. If your hearing was expedited because waiting could put your health at risk, the deadline is shorter: 3 working days for services and benefits, and 7 working days for eligibility and nursing facility transfer or discharge. Ask for the decision in writing, and read it for the reasons and any next step.

The rule

The state must grant a hearing to anyone who believes the agency wrongly denied eligibility or covered services, took an action erroneously, or did not act with reasonable promptness. (Title 42 of the Code of Federal Regulations (CFR), section 431.220(a))

Check the date on your notice, which controls.

Watch for

• Waiting while you try to work it out. Keep the hearing deadline in view even if you are talking with the agency.
• Assuming the format. Do not assume the hearing is by phone or in person. Ask.
• Deciding about a lawyer too late. Vermont’s guide discusses whether you need one. Ask a legal aid office or advocate about your case early.
• Not bringing the doctor’s letter. The reason you need the service is the heart of most service denials.
• State differences. Some states have different deadlines, forms and names for the hearing. Your notice controls.

What next

• Medicaid appeals and fair hearings covers the request, deadlines and continued benefits.
• Legal aid lists free legal help.
• State consumer advocates points you to a state helpline that may help prepare.