Medicaid Denials: Appealing Unfavorable Decisions

The Medicaid application process is difficult and time consuming. The highly complex rules can trip up even the most careful of applicants. Even the county caseworkers who process Medicaid can make mistakes, misunderstand the rules, or even lose your application all together! So, what happens if Medicaid denies your application?

Medicaid eligibility decisions are first made at the county level. Each county Department of Job and Family Services is responsible for determining Medicaid eligibility for those who reside in their county. You, the applicant must provide all the necessary verifications to the county department so that they can determine eligibility. If the county finds that certain eligibility criteria are not met, or that you have not timely provided the needed information, they will deny the case.

At that point, you can appeal the decision. If benefits are going to stop, they will continue until your appeal is resolved if you appeal within 10 business days (not counting holidays or weekends). Otherwise, you have 90 days from the date of the notice to file your appeal to preserve your application date. After 90 days, your only option is to file a new application, and your eligibility and benefits will only be effective at that new application date.

The first level of appeal is called a State Hearing. At this level, a hearing officer will conduct an informal proceeding. The county department will have to show the reason why the application was denied. You then have an opportunity to make your case, and the hearing officer will ask questions as well. Once all the evidence is presented to the hearing officer, he or she will issue a written decision a few days later. The hearing officer may uphold the denial, or they may overrule the denial and return the case to the county with instructions. Rarely, the hearing officer will overrule the county and order the case to be approved. Often cases are incorrectly denied because a verification is overlooked, or information is entered incorrectly. These issues are straightforward to fix and can usually be done by you, but it never hurts to consult with an attorney if you receive a Medicaid denial.

If your appeal is denied at the State Hearing level, you may appeal the hearing officer’s decision to the Department of Medicaid as an administrative appeal. At this level, you must provide a detailed written legal argument as to why the county and state hearing officer are incorrect and this should be handled by an experienced attorney. If the administrative appeal is denied, you can appeal the Department of Medicaid’s decision to the Court of Common Pleas, and from there all the way to the Ohio Supreme Court.

Most Medicaid appeals stop at the State Hearing level. Administrative appeals are rare and appealing beyond to the court system is even rarer. Only a tiny number of Medicaid appeals have gone all the way to the Ohio Supreme Court. Even so, you should always consult with a Medicaid attorney if your application is denied, so they can help handle your appeal or can explain why you were denied and help correct whatever is preventing you from being eligible.

Posted in Areas of Practice, Articles: Elders and Their Caregivers, Blog, Caregiving, Elder Law, Medicaid, Older Adults.