Appeal my Medicaid plan's cut and keep my services going
Ask your Medicaid health plan to appeal a cut or ending of a service you already get, and to keep the service going while it decides. Ask within 10 calendar days of the notice, or before the change takes effect if that is later.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. For a person in a Medicaid managed care plan (a private company the state pays to run Medicaid), or someone helping them, whose plan sent a notice that it will cut, suspend or end a service already approved, such as home health aide hours. It is not for Medicare or for a job-based or individual private plan. You have 60 calendar days from the date on the notice to ask for the appeal. The time to ask to keep services going is much shorter: within 10 calendar days of the date the plan sent the notice, or before the change takes effect if that is later. Phone the plan first if you can (see the phone script) and send this letter the same day. Check the date on your notice, which controls.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals office named on the notice]
Re: Appeal my Medicaid plan's cut and keep my services going Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the appeals office:
I am asking [Name of the health plan] to appeal, review and reverse its decision to reduce or end a service I already receive. I am also asking that the service continue unchanged while the plan decides this appeal. My Medicaid identification (ID) number is [Member ID]. The plan's notice is dated [Date on the denial notice].
The notice says: [What the notice says will change] The change is to take effect on [Date the notice says the change takes effect]. This service was already authorized and was ordered by [The doctor or provider who ordered the service].
I disagree with this decision because: [Why you disagree with the decision]
I ask that you: 1. Accept this as my appeal. If anything more is needed for it to count, tell me right away. 2. Continue my services at the level in place before the notice until the appeal is decided. I am asking for this within 10 calendar days of the date the plan sent the notice, or before the change takes effect if that is later. I understand that the plan may ask me to repay the cost of continued services if the final decision goes against me. 3. Send me my case file, including my medical records and any new evidence, free of charge and early enough before the decision for me to respond. 4. Have the appeal decided by someone who was not involved in the first decision and who has the right medical or long-term care expertise for my needs. 5. Confirm in writing that you received this request, the date you received it, whether my services will continue, and the date you will decide. 6. Send me the decision in writing, and tell me how to ask for a state fair hearing if you uphold the decision.
You can reach me at [A phone number where you can be reached].
Enclosures: 1. Copy of the plan's notice 2. Letter or order from the doctor or provider who ordered the service, if you have one 3. Signed authorization, if someone is writing for the member and the plan requires it
Sincerely, [Your name]
Before you send it
Send it to the appeals address or fax number on the notice, in a way that gives you a receipt, or through the plan's member portal if it gives a confirmation. Phone the number on the notice the same day, because the time to ask for continued services is short. Keep a copy and write down the date and time you sent it. A provider cannot ask for continued services for you, so the member or the member's authorized representative must ask.
What to enclose
- Copy of the plan's notice
- Letter or order from the doctor or provider who ordered the service, if you have one
- Signed authorization, if someone is writing for the member and the plan requires it
What happens next
- Ask by the deadline. To keep services going, ask within 10 calendar days of the date the plan sent the notice, or before the change takes effect if that is later. To appeal at all, ask within 60 calendar days from the date on the notice. The date on your notice controls.
- The plan must continue services during the appeal only if your request is timely, the notice is about ending, suspending or reducing services already ordered by an authorized provider, and the original authorization period has not expired. If the plan says no, ask for the reason in writing.
- If the final decision goes against you, the plan may recover the cost of the continued services, consistent with the state's usual policy.
- The plan must decide within a state-set period of no more than 30 calendar days for a standard appeal, and no more than 72 hours for an expedited appeal. Each can be extended by up to 14 calendar days in limited circumstances.
- Ask for your case file now. The plan must give it to you free of charge.
- If the plan upholds its decision, you must be given no less than 90 and no more than 120 calendar days from the date of the plan's notice of its appeal decision to ask for a state fair hearing. To keep services going through the hearing, ask for the hearing and for continued services within 10 calendar days of the plan's appeal decision. Use the Medicaid fair hearing request letter (“Medicaid fair hearing request”).
- If the plan does not meet the notice and timing rules for the appeal, you are treated as having finished the plan appeal and can go straight to a state fair hearing.
- If you are helping someone else, the plan may require its own authorization form. See the letter "Name someone to act for you".
- Free help: ask your state Medicaid agency's ombudsman or a legal aid office about free representation.
The rule behind this
- 42 CFR 438.402, general requirements for the plan appeal
- 42 CFR 438.406, handling of grievances and appeals (case file)
- 42 CFR 438.408, resolution and notification
- 42 CFR 438.410, expedited resolution of appeals
- 42 CFR 438.420, continuation of benefits while the appeal is pending
- 42 U.S.C. 1396d(r)(5), Early and Periodic Screening, Diagnostic and Treatment
Sources
Denial reasons this answers
- Denial reason
Care is ending
Hospital, rehab, nursing home or home health care ending? Medicare: call the reviewer on your notice by noon the day after you get it, or 1-800-MEDICARE (1-800-633-4227). Medicaid or job-based plan: see What to send.