Medicaid managed care: the plan appeal comes first

Most Medicaid enrollees get care through a managed care plan, a private company the state pays to run their benefits. When that plan denies, limits or cuts a service, the plan’s own appeal comes first. The state’s fair hearing comes second. The reference page is Medicaid managed care plan.

A fair hearing is a phone or in-person meeting where a state hearing officer decides whether the cut or denial was wrong. Your notice may call the plan’s decision an “adverse benefit determination”. That is the official name for a denial, a limit, a cut or an end to a service.

Helping a parent? The plan may ask for written permission first. Ask for its form when you call. See acting for someone else and the authorized representative letter.

Ready-made words. Use the phone script for a Medicaid plan appeal call, then send the letter to appeal and keep your services going.

What this means

The plan’s decision is called an adverse benefit determination. It includes a denial or limit on a service, a reduction, suspension or end of a service that was approved, a denial of payment, and a failure to provide services on time.

A Medicaid plan may have only one level of internal appeal. After that, the state fair hearing is the next step. Some states also offer an outside medical review. That is optional for states. Where it exists, it is your choice, it must be free and independent, and it cannot be required before a fair hearing or hold up your deadlines or your continued benefits. A 2019 review by the Office of Inspector General found that only 14 of 37 states studied offered one.

If you have both Medicare and Medicaid, you may be in a plan that runs one combined appeal for both. See the last section.

What to do

1. Read the plan’s notice (you). Find the reason and the date. If you already receive the service, find out the date it will end.
2. Ask for continued benefits quickly if the service is already approved and being cut (you). The plan must keep the benefit going during the appeal if: your appeal is on time; the case involves ending, suspending or reducing a service an authorized provider ordered; the original approval period has not run out; and you ask for continuation within 10 calendar days of the date the plan sent the notice, or before the intended date of the change, if later. Your provider cannot ask for continuation for you.
3. File the plan appeal (you). You have 60 calendar days from the date on the notice. You can ask by phone or in writing. With your written consent, and if state law allows, your provider can file for you.
4. Ask for the case file (you). The plan must give you the case file, including your medical records and any new evidence, free of charge and early enough before the decision deadline.
5. Ask for a fast appeal if waiting could harm you (you and your doctor). The plan must decide within 72 hours. A standard appeal is decided within a state-set period of up to 30 calendar days. Either can be extended by up to 14 calendar days in limited circumstances.
6. If the plan says no, ask the state for a fair hearing (you). You must be given no less than 90 and no more than 120 calendar days from the date of the plan’s notice of its decision. To keep benefits going through the hearing, request the hearing and continuation within 10 calendar days of the plan’s adverse appeal decision.
7. Know the shortcut (you). If the plan fails to meet the notice and timing requirements for its appeal, you are treated as having finished the plan appeal and can go straight to a state fair hearing.

Check the date on your notice, which controls.

How long the plan has to approve care

When you first ask for a service, a plan’s standard decision on an authorization request must come within 14 calendar days for contract periods that start before 1 January 2026, and within 7 calendar days for those that start on or after that date. A fast decision is 72 hours, extendable by up to 14 days. A decision not made in time counts as a denial. Because the 7-day rule is tied to the start of each state’s contract period, the date it starts differs by state.

A person with appropriate expertise in your medical, behavioral health or long-term care needs must make any decision to deny or approve less than requested.

The rule

You have 60 calendar days from the date on the plan’s notice to ask for its internal appeal, and then no less than 90 and no more than 120 calendar days from its notice of resolution to request a state fair hearing. (Title 42 of the Code of Federal Regulations (CFR), section 438.402; 42 CFR 438.408(f)(2))

Watch for

• Repayment. If the final decision goes against you, the plan may recover the cost of services it kept going, consistent with the state’s usual policy.
• If you win. If services were not provided during the appeal, the plan must authorize or provide them within 72 hours of receiving the decision.
• Few people take the next step. In the 2019 data from 115 plans run by the 7 largest parent companies in 37 states, the Office of Inspector General found that enrollees appealed 11 percent of denied prior authorization requests, plans reversed 36 percent of the appealed denials, and only 2 percent of upheld denials went on to a state fair hearing. This is old data about the plans studied. It does not predict your case.
• Complaints are different. You can file a grievance, which is a complaint other than a coverage decision, with the plan at any time. The state sets the time limit for resolving it, which may not exceed 90 calendar days.
• Combined Medicare and Medicaid plans. Certain plans for people with both Medicare and Medicaid, called applicable integrated plans, must run one unified appeal for both programs. It must be requested within 60 calendar days of the denial (receipt presumed 5 days after the notice date), may be made orally, and is decided in 30 days or 72 hours if fast. Benefits for both programs continue if you ask within 10 calendar days. After that, Medicare benefits are forwarded automatically to the outside reviewer, and for Medicaid benefits you can ask for a fair hearing. Other plans for people with both programs appear to follow the ordinary rules for each program, but we could not confirm this, so read your notice closely.
• Your state may have more. The state pages show the state fair hearing deadline and agency. Find yours on the state pages.

What next

• What a Medicaid fair hearing is like explains the second step.
• Medicaid appeals and fair hearings covers decisions made by the state agency itself.
• State consumer advocates lists free help in your state.
• Medicaid and children’s coverage lists every page in this group.