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medicaid fair hearing

The Medicaid Fair Hearing Process – Important Information to Know

If your application for Medicaid has been denied or not acted upon promptly, you have the right to a fair hearing. Here’s what you need to know:

Q: What is a fair hearing?

A: A fair hearing is a proceeding before an administrative law judge (ALJ). If you feel that the decision made by the Department of Social Services (or Managed Long Term Care Agency) on your Medicaid application was incorrect, you have the right to request a fair hearing. The three most common reasons to request a fair hearing are:

  1. A decision that you are not eligible for Medicaid (a denial);
  2. A decision that denies, suspends, reduces, or stops existing Medicaid coverage for a service; or
  3. A failure to act upon your request for Medicaid eligibility or for service coverage.

You can also request a fair hearing if you are receiving care at home and need to request more hours.

Q: How do I request a fair hearing?

A: To request a fair hearing you need to act promptly. A fair hearing MUST be requested within 60 days of the date of the Medicaid Notice for which you are appealing. You will receive a Medicaid Notice in the mail indicating the date, place, time and reason for the hearing. If you miss the deadline, you will be barred from requesting a hearing and the Medicaid Notice will stand.

Q: What documentation are you expected to provide at the fair hearing?

A: If the hearing involves medical issues, the ALJ may deem it necessary to have a new medical assessment conducted. This assessment will be obtained at the State’s expense and made part of the hearing record. You will also have the opportunity to examine and be given access to the following (upon request) before the hearing:

  • The content of your case file; and
  • All documents that the Agency (Medicaid) will use at the hearing;

You may also:

  1. Bring witnesses;
  2. Bring documentary evidence to submit a the hearing in support of your case; and
  3. Question or refute any testimony or evidence provided by the Agency.

Q: How long does a fair hearing last?

A: A fair hearing is like a trial, but not as formal. You have to present all of the evidence you have to prove that the caseworker’s decision was wrong. You may also need to make legal arguments in support of your position on eligibility for benefits. Depending on the issues, it is not uncommon for a hearing to last an hour or more. The decision is not made at the end of the hearing. It is usually mailed within 2-4 weeks of the hearing.

Q: Who makes the final decision for your Medicaid status at a fair hearing?

A: The ALJ in a fair hearing gathers all of the evidence, takes any testimony, can ask questions, and will then compile a record of the hearing and recommendation. The case record is then sent to Albany to the Office of Temporary and Disability Assistance from which the written decision is rendered. If the fair hearing decision finds fault with the Medicaid determination, then the Agency will be required to follow the hearing decision. This may include overturning the Medicaid decision as incorrect, or may require the Agency to continue to process a Medicaid application with information or documentation that was submitted at or prior to the hearing.

Q: Can I resolve a negative determination without having to attend or request a fair hearing?

A: You may be able to request that the Medicaid agency conduct a “reconsideration” of the denial or other adverse determination. Although there is no law for this process, if an Agency is willing to reconsider, the request usually must be made within 30 days of the determination. This process usually involves submitting documentation that may have been missing but was obtained subsequent to the Medicaid determination. If you are not satisfied with the reconsideration results, you still have the right to a fair hearing (but it still MUST be requested within 60 days of the original Medicaid determination).

It’s important to understand the Medicaid fair hearing process should your application be denied or delayed. There are steps to take to rectify this situation and ensure you get the services you need. If you have any questions, please contact us. We would be more than happy to discuss your situation and counsel you through this process.

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