Medicaid managed care plan

Who this covers

This page is for people whose Medicaid care is delivered through a managed care plan. If your state pays your providers directly, see Medicaid fee-for-service. If you have both Medicare and Medicaid, read the notes below, then see Medicare Advantage. Read the Medicaid managed care appeals guide or use the Medicaid hearing planner.

How to tell this is your coverage

The denial comes from your plan, not from the state. It must say what the plan decided and how to appeal. Since 1 January 2026 the plan’s standard authorization decision must come within 7 calendar days for contract rating periods that start on or after that date, and within the state’s time (no more than 14 calendar days) for earlier periods. That means the start date differs by state. An expedited decision is due within 72 hours and can be extended by up to 14 calendar days. A decision not made in time counts as a denial. The seven-day rule does not cover drugs. Anyone who denies a service or approves less than you asked for must have appropriate expertise in your medical, behavioral health or long-term services needs.

What does not apply to you

You do not go straight to a fair hearing. The plan appeal comes first, unless the plan misses its notice and timing requirements. The fee-for-service rule of “up to 90 days from the mailing date” does not apply to your first step; your plan appeal has 60 days.

External medical review is optional for states. If your state offers it, it must be your choice, free, independent of the state and the plan, and cannot be required before a fair hearing or extend deadlines. The Office of Inspector General’s review of 2019 data covering 37 states found that only 14 offered it.

If you have both Medicare and Medicaid in an integrated plan (a fully or highly integrated dual eligible special needs plan with exclusively aligned enrollment, with its matching Medicaid plan), one combined appeal process replaces the separate plan rules. You have 60 calendar days after receiving the denial to file, and an oral request counts. The plan decides within 30 calendar days, or 72 hours if expedited. Benefits for both Medicare and Medicaid services continue during that appeal if you ask within 10 calendar days of the plan sending the notice (or before the effective date, if later) and the other conditions are met. After the combined appeal, Medicare-covered benefits are sent automatically to the independent review entity, and for Medicaid-covered benefits you may ask for a state fair hearing. Other plans for people with both programs appear to follow the ordinary rules for each program, but we could not confirm this, so read your notice closely.

Where people go wrong

• Skipping the plan appeal. Without the plan appeal you generally cannot reach the hearing, unless the plan failed its own notice and timing rules.
• Missing the 10-day continuation request. It has its own 10-day deadline, separate from the 60-day appeal deadline. A provider cannot ask for continuation for you.
• Not appealing at all. In an Office of Inspector General review of 2019 data from 115 Medicaid managed care plans run by the 7 largest parent companies in 37 states, plans denied about 2.2 million prior authorization requests, 1 in 8 (12.5%). Enrollees appealed 11% of denials, and plans reversed 36% of appealed denials. Only 2% of upheld denials went on to a state fair hearing. This describes that sample and does not predict your result.
• Assuming “not a covered benefit” ends it for a young person. For people under 21, the state must provide any service that federal Medicaid law allows and that is medically necessary to correct or ameliorate conditions found by screening, whether or not the state plan covers it. This is called Early and Periodic Screening, Diagnostic and Treatment. The state decides case by case. Whether a hard visit limit can be challenged this way is a common legal reading that we could not confirm in federal guidance, so ask free legal aid.
• Confusing a complaint with an appeal. A grievance about something other than a coverage decision can be filed with the plan at any time, and the state sets its resolution time, up to 90 calendar days. It does not replace an appeal.

Free help is listed above.