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What If I’ve Been Turned Down For Medicaid or CHIP Coverage?

Researcher & Writer

February 06, 2016

First off, please note that if you are denied Medicaid benefits, you will find out through a written notice. Being told you were refused by a caseworker is not sufficient. You need to receive written notice.

If you applied for Medicaid based on disability, the state is required to either accept your application or provide a notice of denial within 90 days. If you were applying for Medicaid for a reason other than disability, you need to be notified within 45 days.

In the written notice, you will be informed of the reasons why you application was denied and the specific state regulation used in denying your application. It will also inform you that you have a right to an appeal hearing. It will provide instructions on how to request an appealing hearing. For this hearing, you will have the right to represent yourself, hire a lawyer, or designate a legal representative to appear at the hearing in your place.

Last, but certainly not least, the denial notice will include the deadline for your right to appeal. Deadlines are chosen by the state. However, it will be no more than 90 days from the date on the denial letter. The denial notice should be kept until after the appeal process is complete.

Regardless of whether or not you are required to submit your request for an appeal in writing, you should do so. You should also deliver it to your local Medicaid office for the appeal. When you drop off your letter, you can make sure it is timestamped, so there is no confusion over whether or not you submitted the letter on time.

The request for an appeal does not have to be lengthy or provide the reasons you want an appeal. It can simply state, “I am requesting an appeal for the Medicaid denial dated xx/xx/xxxx.”

Once your appeal request is processed, you will receive a hearing date, and you will be required to show up at that hearing. Some states allow you to “appear” via phone. If you do not appear for your hearing, your request for an appeal will be dismissed. If you miss your hearing date, the only way your appeal can be salvaged is if you can provide documentation for a justifiable reason.

Forgetting the date is not a justifiable reason. Something like a health problem or an unexpected transportation issue, however, is a justifiable reason.

For example, if you were in the hospital on the date of the hearing or your car broke down on the way to the hearing - these are viable excuses that you can prove and may be considered justifiable.

Note that each state conducts their hearings differently. You will receive a letter in the mail explaining how the hearing will go. Knowing what to expect will help you prepare. When preparing for your hearing, go back to the denial letter you received to address the reasons you were denied. Put together any documentation or witnesses you need to appeal the specific reasons you were denied.

If, during the trial, something comes up that you can provide documentation for, you can ask the judge for more time before a decision is made on your appeal. If you applied for Medicaid based on disability, the judge might request a medical exam. If this happens, you are required to get the additional exam, or your appeal is dismissed. If an additional exam is requested, the cost will be covered by the state.

You will receive a letter in the mail letting you know the outcome of the hearing. If you are denied again, you will again be provided with information on how you can appeal. Depending on the state, the second appeal may not be a hearing. Instead, you may have to simply submit your arguments against the denial in a written letter to be considered.

If you win your appeal, you will receive the Medicaid coverage you applied for, and it will be applied retroactively to the date you originally applied. For that reason, it is important to keep documentation of all medical expenses from the time you apply. You’ll be able to submit all those expenses to Medicaid to be covered.

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