Medicaid Appeals: How To Challenge a Denial or Termination of Coverage

When your Medicaid application is denied or your coverage is reduced, terminated, or suspended, it can be stressful and confusing. In most states, you have the right to appeal and ask the agency to review or reverse its decision.

This guide from HowToGetAssistance.org explains, in plain language, how Medicaid appeals typically work and what steps you can take through official state and local offices. This site is not a government agency, not an application portal, and not a legal service. It is an informational resource to help you understand your options.

Understanding Medicaid Decisions: Denials, Terminations, and Reductions

Before you appeal, it helps to know what type of decision you are challenging.

Common types of negative Medicaid decisions

Your state Medicaid agency may send you a written notice that says something like:

• Application denied – you are not approved for Medicaid.
• Coverage terminated – your current Medicaid will end on a certain date.
• Coverage reduced – for example, you move from full coverage to limited benefits.
• Services denied or reduced – a specific service, treatment, or home care hours are not approved or are cut back.
• Enrollment suspended – coverage is temporarily paused.

The notice usually includes:

• The reason for the decision.
• The effective date (when it starts).
• Your appeal rights and deadline to request a hearing or review.
• How to contact your state agency or local Medicaid office.

If you did not receive a notice, or if it is hard to understand, you can contact:

• Your local Medicaid office, or
• Your state’s Medicaid customer service or call center

and ask them to explain the decision and provide a copy of the notice in writing.

Do You Have the Right to Appeal a Medicaid Denial or Termination?

In most cases, yes. Medicaid is regulated by federal and state rules that generally give you a right to:

• Receive written notice when Medicaid is denied, reduced, or terminated.
• Request an appeal (often called a “fair hearing” or “eligibility hearing”).
• Present evidence and explain your situation.
• Have someone represent you, such as a lawyer, legal aid advocate, or trusted person.

However, deadlines and procedures vary by state. Many states require you to request an appeal within 10–30 days of the date on the notice. Some states allow more time for certain types of appeals.

If you miss the deadline, you may lose your right to appeal that specific decision.

Step 1: Carefully Read Your Medicaid Notice

Your denial or termination letter is your roadmap. Read it slowly and look for:

• What was decided

  • Denied application
  • Termination of coverage
  • Reduction in a benefit or service

• Why the decision was made
  Common reasons include:

  • Income above the program limit
  • Missing documents (proof of income, identity, or residency)
  • Failure to respond to a renewal or verification request
  • Change in household (marriage, divorce, moving, etc.)
  • Not meeting immigration or citizenship requirements
  • Not meeting disability-related criteria (for certain Medicaid categories)

• Effective date
  When the termination or change will start.

• Appeal deadline
  Often shown as “You have X days from the date of this notice to request a fair hearing.”

• Where to send your appeal
  This may be:

  • A state hearing office
  • The Medicaid agency
  • A county human services department

If anything is unclear, call the number listed on your notice or speak to your local Medicaid office and ask them to explain your appeal options in plain language.

Step 2: Decide Quickly if You Want to Appeal

Because appeal deadlines are often short, do not wait if you think the decision is wrong or incomplete.

You might consider appealing if:

• You believe the state used wrong or outdated information.
• Your income or household situation changed and was not correctly counted.
• You did send documents, but the agency did not receive or process them.
• You believe the agency misapplied the rules.
• Your coverage is being terminated even though nothing has changed.
• Critical services (such as personal care or home health) were reduced or denied and you disagree.

If you are not sure, you can often file the appeal first to protect your deadline and gather more information afterward.

Step 3: Know the Typical Appeal Timelines and What They Mean

Exact timelines vary by state, but here is a general idea of what you may see.

*These are typical ranges, not guarantees. Always rely on the deadline written on your official notice or confirmed by your state agency.

Step 4: Gather Documents and Information for Your Medicaid Appeal

Having organized documents can make your appeal stronger and easier to understand.

Helpful documents to collect

Depending on why you were denied or terminated, you may want:

• The denial or termination notice itself (very important)
• Proof of identity (ID card, driver’s license, state ID)
• Proof of citizenship or immigration status, if relevant
• Social Security numbers (or documentation that you applied)
• Proof of income, such as:
  • Pay stubs
  • Employer letter
  • Self-employment records
  • Unemployment benefits statements
  • Social Security benefit letters
• Proof of assets, if your program has asset limits:
  • Bank statements
  • Retirement account statements
  • Property documents
• Proof of household size:
  • Birth certificates for children
  • Marriage or divorce records
  • Custody or guardianship documents
• Proof of residency:
  • Lease, mortgage, or utility bill
  • Official mail to your address
• Medical records or provider letters, if your appeal relates to disability status or denial of a service
• Any letters, emails, or notes from conversations with the Medicaid office or managed care plan

Keep copies of everything you send and, if possible, note dates for each contact or submission.

Step 5: Learn the Types of Medicaid Appeals in Your State

Appeal structures differ across states, but you may encounter:

1. State Fair Hearing (Administrative Hearing)

This is the most common type of appeal. It typically involves:

• Filing a written request (sometimes a form) for a hearing.
• Having your case reviewed by an impartial hearing officer or administrative law judge.
• Presenting evidence, documents, and your explanation.
• Receiving a written decision after the hearing.

2. Managed Care Plan Appeals (if you are in an MCO)

If you are enrolled in a Medicaid managed care organization (MCO) or health plan, and the plan:

• Denies a service,
• Reduces a service, or
• Refuses to pay for a service,

you may have to:

1. Appeal to the plan itself first (internal appeal or grievance), and
2. If you still disagree, request a state fair hearing afterward.

Check:

• Your health plan member handbook, or
• The customer service number on your insurance card

to learn your specific appeal rights and deadlines for plan decisions.

3. Expedited or “Fast-Track” Appeals

Some states and plans allow expedited appeals when waiting for a standard decision could seriously risk your health, life, or ability to function.

For example, you may request an expedited appeal if:

• A needed medication is denied.
• Home care services are suddenly reduced, and you cannot safely manage without them.

Your doctor or provider may need to support the request for an expedited review. The plan or agency will then decide whether it qualifies for faster handling.

Step 6: How to File a Medicaid Appeal

The exact steps depend on your state and the type of decision. In general:

1. Follow the instructions on your notice

Your notice should explain:

• How to appeal (mail, fax, online portal, phone, or in person).
• Where to send or deliver your appeal.
• What information to include.

Many states prefer written appeals so there is a clear record.

2. What to include in a written appeal request

While states have their own forms, a simple written appeal often contains:

• Your full name
• Your Medicaid ID number (or case number)
• Your address and phone number
• A statement such as:
  • “I am requesting an appeal (or fair hearing) regarding the decision dated [notice date] that denied/terminated/reduced my Medicaid benefits.”
• A brief explanation of why you disagree
  • For example: “The income used in the decision is incorrect,” or “My disability and medical needs were not fully considered.”
• Your signature and the date

Keep a copy of what you send, along with any proof of submission (certified mail receipt, fax confirmation, online confirmation page, etc.).

3. Submitting through different channels

Depending on your state, you may be able to submit your appeal:

• By mail – to the address on the notice (allow time for delivery).
• By fax – keep confirmation pages.
• Online – through your state’s official benefits portal.
• In person – at your local Medicaid or county human services office.

If you are unsure whether you are using an official channel, you can:

• Call your state Medicaid agency’s main number (listed on the state government website).
• Ask them to confirm the correct address, fax number, or online portal for appeals.

Step 7: Can Your Medicaid Stay Active During the Appeal?

In many states, if you are currently enrolled in Medicaid and you appeal a termination or reduction before the effective date, you may be able to keep your existing coverage:

• This is often called “aid paid pending” or “continued benefits during appeal.”

Important details:

• You may need to specifically request continued coverage when you file your appeal.
• If you lose the appeal, some states may bill you or recover costs for services paid during the appeal period. Ask your state agency how this works where you live.
• If you appeal after the date your coverage ends, you might not qualify for continued coverage while the appeal is pending.

Your appeal notice or state Medicaid website should explain how continued benefits work in your state. If not, ask your local office or call center directly.

Step 8: Preparing for Your Medicaid Hearing or Review

If your appeal leads to a hearing, it may be held:

• In person at a hearing office or local agency
• By phone
• By video conference

You will receive a notice of hearing with the date, time, and method.

What typically happens at a hearing

• A hearing officer or judge explains the process.
• A representative from the Medicaid agency or health plan may be there.
• You (and your representative, if you have one) can:
  • Explain your side.
  • Present documents and evidence.
  • Call witnesses, such as a doctor or case manager (varies by state).
  • Ask questions about the agency’s evidence.
• The hearing is usually recorded, and you will receive a written decision later.

How to prepare effectively

• Review your denial notice and any letters from the agency or plan.
• Organize your documents in a clear order:
  • Income proof
  • Medical records
  • Letters from doctors or specialists
  • Proof that you submitted requested information on time
• Write down key points you want to make:
  • What the agency got wrong
  • Any changes in your situation
  • Why you meet the eligibility rules (as you understand them)
• Practice explaining your situation briefly and clearly.
• Make sure you attend the hearing on time. If you cannot attend:
  • Contact the hearing office in advance to ask about rescheduling.

Step 9: Getting Help With Your Medicaid Appeal

You do not have to go through the appeal process alone. Help may be available from:

1. Legal aid and advocacy organizations

Many communities have legal aid offices or public interest law organizations that:

• Help people with Medicaid appeals,
• Provide free or low-cost advice, and
• Sometimes represent individuals at hearings (depending on capacity).

You can search for local legal aid by:

• Calling 211 (in many areas) and asking for help with Medicaid or health benefits appeals.
• Contacting your state or county legal aid society, law help line, or disability rights organization.

2. Community-based organizations

Some nonprofits, clinics, and social service agencies have staff who:

• Help with Medicaid applications and renewals,
• Help gather documentation, and
• Sometimes assist with appeals or connect you to legal help.

3. Health care providers

In some cases, your:

• Doctor’s office,
• Hospital social worker, or
• Clinic case manager

may be able to provide supporting letters or help explain why certain services are medically necessary. They may also help you understand plan decisions and appeal options, especially for denied services.

Step 10: After the Decision – What If You Win or Lose?

If your appeal is successful

If the hearing officer or agency decides in your favor, you may see:

• Approval of your Medicaid application, possibly backdated.
• Reinstatement of your coverage, sometimes with backdated coverage.
• Restoration of services, such as home care hours.
• Correction of your income or household information in the system.

Review the written decision carefully to understand:

• What was granted,
• From what date, and
• Whether you need to complete any additional steps.

If coverage is not updated within a reasonable amount of time, contact your local office or state Medicaid customer service to ask about the status.

If your appeal is denied

If you lose the appeal, the decision notice may explain:

• Whether there is a second level of appeal (for example, a state court review or external review for managed care).
• How and when you can reapply for Medicaid if your situation changes.
• Whether you might be eligible for other programs, such as:
  • Marketplace health coverage with subsidies (through the federal or state marketplace),
  • Children’s health programs (like CHIP),
  • Local health clinics or charity care programs.

You may wish to:

• Speak with a legal aid attorney about possible next steps.
• Ask your state agency or local office if they can explain what would need to change for you to qualify in the future.

Common Reasons Medicaid Is Denied or Terminated (and What You Can Do)

Understanding why people are often denied can help you respond more effectively.

1. Income appears too high

• The agency may have:
  • Counted gross income instead of allowable net income.
  • Included income from someone who should not be counted in your household.
  • Missed certain deductions or disregards.
• What you can do:
  • Provide current pay stubs or an employer letter if your hours changed.
  • Clarify who lives in your household and who is financially responsible.
  • Ask your caseworker to explain how your income was calculated.

2. Missing or late documents

• Commonly missing items:
  • Proof of identity or citizenship
  • Income verification
  • Residency proof
• What you can do:
  • Submit the missing documents as soon as possible.
  • Keep proof of when you submitted them.
  • If you already sent them, tell the agency and provide copies again for the appeal.

3. Failure to respond to renewal or verification requests

• Many states require yearly renewals or periodic checks.
• If mail is not received or returned on time, coverage can be terminated.
• What you can do:
  • Update your mailing address with your Medicaid agency.
  • Ask if the renewal can be reopened or if you need to reapply.
  • Consider using any available online account to track messages and deadlines.

4. Immigration or citizenship issues

• Some Medicaid programs require certain citizenship or immigration statuses.
• Other options sometimes exist for:
  • Emergency services,
  • Pregnant individuals, or
  • Children, regardless of certain statuses (depending on the state).
• What you can do:
  • Provide any immigration documents requested.
  • Ask the agency which specific category you were denied under.
  • Look into alternative state or local health programs for those who do not qualify for full Medicaid.

5. Disability-related denials

For disability-based Medicaid (often linked to Supplemental Security Income or similar programs), denials may happen if:

• The agency decides your condition is not severe enough under program rules.
• There is limited medical evidence in your file.

What you can do:

• Gather up-to-date medical records.
• Ask your doctor to provide a letter explaining your limitations and needs.
• Consider talking to a legal advocate experienced with disability appeals.

Verifying You Are Using Official Medicaid Channels (Avoiding Scams)

Because Medicaid involves personal and financial information, it is important to be sure you are dealing with official offices and portals.

Here are some practical tips:

• Look for .gov in web addresses for state and federal government websites.
• Call the phone numbers listed on:
  • Your official Medicaid notice
  • Your insurance card (for managed care plans)
  • Your state’s main government or health department website
• Be cautious if:
  • Someone asks for money to process your appeal (official appeal filings are typically free).
  • A person or website promises guaranteed approval.
  • You receive unsolicited calls or texts requesting your full Social Security number or bank details.
• If unsure, contact:
  • Your local Medicaid office,
  • Your state’s Department of Human Services, Health Department, or Medicaid agency, or
  • Call 211 and ask how to reach your official state benefits office.

Alternatives and Next Steps if You Do Not Qualify for Medicaid

If after appealing you still do not qualify for Medicaid, you may explore:

• Children’s Health Insurance Program (CHIP) in your state, if you have children who need coverage.
• Health insurance marketplace plans (through the federal or state marketplace), which may offer subsidies based on income.
• Community health centers and free or sliding-scale clinics, which offer reduced-cost care.
• Hospital financial assistance or charity care programs, especially for large medical bills.
• Local public health department services (immunizations, screenings, certain treatment programs).

You can ask:

• Your local health department,
• A community clinic, or
• 211

for help locating health care resources in your area.

By understanding your appeal rights, acting quickly, organizing your documents, and using official channels, you give yourself the best chance to correct mistakes and keep or regain the Medicaid coverage you may be eligible for.