Medicaid appeals and fair hearings

Medicaid is run by each state within federal rules. If your state Medicaid agency denies, cuts or stops your benefits or your eligibility, you can ask for a fair hearing. This page covers the standard (fee-for-service) route, where the state agency itself makes the decision. If you are in a Medicaid managed care plan, the plan’s own appeal comes first. See Medicaid managed care: the plan appeal comes first. The reference page is Medicaid (fee-for-service).

A fair hearing is a phone or in-person meeting where a state hearing officer decides whether the cut or denial was wrong. Your notice may call the decision an “adverse benefit determination”, which is the official name for a denial, a limit, a cut or an end to a service.

To keep your services going, say so when you ask. Say: “I want a fair hearing, and I want my services to continue until it is decided.” Do it before the date the change takes effect. If you are in a Medicaid health plan, use the plan’s appeal steps in the managed care guide, the phone script for a Medicaid plan appeal call and the letter to appeal and keep your services going.

Helping a parent? The plan may ask for written permission first. Ask for its form when you call. See acting for someone else and the authorized representative letter.

What this means

The state must tell you in writing, at the time of application and whenever it denies eligibility, benefits or services or takes another adverse action, about your right to a fair hearing, how to ask for one, your right to be represented, and the deadlines for a decision. A notice of adverse action must state:

• what the agency intends to do and the date it takes effect;
• the specific reasons;
• the specific regulations behind the action;
• your right to a hearing; and
• when benefits continue if you ask for a hearing.

If the state plans to end, suspend or reduce your eligibility or services, it must generally send notice at least 10 days before the date. Shorter notice is allowed in set cases, such as a confirmed death or your own signed request, and in cases of probable fraud the period can be 5 days.

You are entitled to a hearing if you believe the agency wrongly denied eligibility or covered services, acted wrongly, or did not act with reasonable promptness. Nursing facility residents facing transfer or discharge also have the right.

What to do

1. Read the notice for the deadline and the reason (you). Federal law does not set one number of days for asking. The state must allow “a reasonable time, not to exceed 90 days” from the date the notice was mailed. States set their own limit anywhere up to 90 days. The state pages record deadlines as short as 20 business days to 30 days for some decisions made by the state agency itself, so read your own notice, and look up your state on the state pages.
2. Ask for the hearing in writing before the date the change takes effect (you). Follow the instructions on the notice. If you ask before the date of action, the state may not end or reduce your services until the hearing decision, unless the only issue is a federal or state law or policy.
3. If the change has already taken effect, ask within 10 days (you). The state may reinstate your services if you ask within 10 days after the date of action. It must reinstate them only if all three are true: it acted without the required advance notice; you asked within 10 days of receiving the notice (receipt presumed 5 days after the notice date); and the agency finds the action resulted from something other than applying federal or state law or policy.
4. Ask for an expedited hearing if waiting could harm you (you and your doctor). The state must offer a faster process when the standard time could put your life, health or ability to function at risk. The decision is due within 3 working days for services and benefits, and within 7 working days for eligibility claims and nursing facility transfer or discharge.
5. Gather your papers (you, your doctor). A letter from your doctor, your records and the notice itself. See what a Medicaid fair hearing is like.
6. Expect a decision in about 90 days (the state). The state must ordinarily take final action within 90 days of your hearing request.

Check the date on your notice, which controls.

Prior authorization times

Since 1 January 2026 the state Medicaid agency must decide a standard prior authorization request for fee-for-service within 7 calendar days, which it can extend by up to 14 days, and a fast request within 72 hours, unless state law sets a shorter time. Drugs are not included.

If the patient is under 21

For Medicaid enrollees 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 the service. This is called Early and Periodic Screening, Diagnostic and Treatment (EPSDT). A denial that rests on “not a covered benefit” or an adult rule can be challenged under this standard, and the state decides medical necessity case by case. Whether a hard visit limit is allowed under EPSDT is a common legal reading that this site has not confirmed in agency guidance.

The rule

Medicaid must give you “a reasonable time, not to exceed 90 days from the date that notice of action is mailed” to request a fair hearing. (Title 42 of the Code of Federal Regulations (CFR), section 431.221(d))

Watch for

• Repayment. If the hearing upholds the agency, the state may recover the cost of services provided only because benefits were continued.
• A shorter state limit. Do not rely on a figure of 90 days from an article. Use the date on your notice.
• Work requirements in 2027. For coverage on or after 1 January 2027, states must require certain adults aged 19 to 64 in the expansion group to show 80 hours a month of work or other qualifying activity. If the state cannot verify, it must send a notice and allow 30 calendar days to respond before denying or ending coverage. Expect eligibility notices to change. This site has not confirmed how the new rule interacts with fair hearing and continued benefit rights, so appeal on time.
• Billing. Bills keep arriving while you appeal. Handle the bill while you appeal explains what to do.

What next

• What a Medicaid fair hearing is like prepares you for the day.
• Medicaid managed care: the plan appeal comes first covers plan decisions.
• Legal aid tells you where to find a free lawyer.
• Medicaid and children’s coverage lists every page in this group.