Medicaid fair hearing request
Ask your state for a fair hearing when Medicaid denied, reduced or stopped a service. If you have a Medicaid plan, you appeal to the plan first.
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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. When the state Medicaid agency denied, cut or ended a benefit, or did not act in reasonable time, or when your Medicaid plan has decided your appeal. You can use it for a first request to the state (ordinary Medicaid), or after a plan's appeal decision. If you are in a Medicaid managed care plan and have not yet appealed to the plan, appeal to the plan first, within 60 calendar days of its notice, using the letter "Appeal my Medicaid plan's cut and keep my services going", and use this letter after the plan's decision. The state sets your deadline, up to 90 days from the date the notice was mailed for ordinary Medicaid. Take the exact number from your notice.
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 hearing office named on your Medicaid notice]
Re: Medicaid fair hearing request Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am asking for a fair hearing about a decision on my Medicaid coverage. The notice is dated [Date on the denial notice]. My Medicaid identification (ID) number is [Member ID], and the agency or plan that sent it is [Name of the health plan]. The decision concerns [The care or drug that was denied].
What the notice says was decided: [What the notice says was decided]
I believe the decision is wrong because: [Why you believe the decision is wrong]
I ask that you: 1. Schedule a fair hearing and tell me in writing the date, the time and how to take part. 2. Send me a copy of my case file and the rules the agency relied on. 3. Let me know that I may be represented by a person I choose, and tell me whom to contact for questions. 4. Send me the decision in writing.
I am making this request within the time my notice allows, or I ask that you accept it as timely. I am sending it in writing so that there is a record of the date. Please tell me right away if you need anything else from me to schedule the hearing, and if a date is already set, send it to me.
Enclosures: 1. Copy of the notice you received 2. Copy of your plan appeal and the plan's appeal decision, if you already appealed to a plan 3. Letter from your doctor and records that support the request
Sincerely, [Your name]
Before you send it
Send it to the address or fax number on your notice, which must explain how to ask for a hearing, or follow the phone or online instructions it gives. Keep proof of the date and a copy. If you are unsure where to send it, call the number on the notice and ask for a reference number.
What to enclose
- Copy of the notice you received
- Copy of your plan appeal and the plan's appeal decision, if you already appealed to a plan
- Letter from your doctor and records that support the request
What happens next
- Take your deadline from your notice. Federal law lets the state allow a reasonable time that does not exceed 90 days from the date the notice was mailed; states choose the number.
- For a Medicaid managed care plan, you must have no less than 90 and no more than 120 calendar days from the date of the plan's appeal decision to ask for a state fair hearing.
- To keep services going, ask for the hearing before the date the notice says they will end. This protects services that were already approved. It may not apply if the only issue is a change in law or policy. If you lose, you may have to repay. In managed care, ask for continued benefits within 10 calendar days of the plan's appeal decision. Providers cannot ask for you.
- The state must ordinarily reach a final decision within 90 days of the hearing request (for a managed care plan, 90 days from the date you filed the plan appeal). An expedited hearing for a service claim is decided within 3 working days, and for an eligibility claim within 7 working days.
- If you lose, the state or plan may recover the cost of services it continued only because you asked for a hearing.
- Ask your state's Medicaid agency or a legal aid office about free representation. You have the right to be represented at the hearing.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".