If I Disagree With the Eligibility Determination, Can I Fight It?

Researcher & Writer
January 24, 2016

If you do not agree with your Medi-Cal eligibility determination, you can appeal that decision. When a decision is made, you will receive a Medi-Cal Notice of Action (NOA) in the mail. If you are approved, the NOA will include information on your eligibility and benefits. If you are denied, it will include information on your right to a hearing and how to appeal.

The NOA will include a deadline to submit your appeal. This is critical because if you miss the deadline, you will not be able to appeal the decision. When you request an appeal, a hearing will generally be scheduled within 45 days and a decision made within 90 days. You can represent yourself at the hearing or hire an attorney.

Arguing a denial can get complicated. While you are not required to use an attorney, it may be advisable. If you decide to go without a lawyer, it is important to do some research in advance. You will need to know exactly why you were denied including the statue used as the basis for your denial.

You will need to have a solid argument prepared for why that statute should not be applied to your situation. Finally, you will need to provide documentation to support your argument. An attorney experienced with Medi-Cal appeals can help significantly when preparing for the hearing. The attorney can also help you gather and prepare the needed documentation for your appeal.

You can also have an appointed representative go to the hearing your behalf. The representative would have to be chosen and submitted to the court before the hearing. If you are applying on the basis of disability, there are multiple social service organizations that may be able to help and provide an appointed representative that is familiar with the appeal process.

Medi-Cal eligibility decisions are made at the county level, so your initial appeal is at the county level. If your appeal is turned down, you can appeal the decision again to the State Superior Court. This court oversees decisions made in all counties.

If your appeal is denied at the State level, you are temporarily out of options. If anything about your situation changes, you can reapply. For example, if your household gets bigger or your income is reduced for any reason, you can reapply under income eligibility.

If you have a solid case for your appeal, the denial may actually be overturned prior to the hearing. Several counties throughout California are known for relooking at cases prior to the hearing. If they feel there is a solid basis for the appeal, they’ll go ahead and overturn the decision. If you’re denial is not overturned prior to the hearing, this does not mean they don’t feel you have a strong case. Not all counties go through these review process, and it is the judge that makes the final decision.

Written by
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