Alabama Medicaid Appeals and Fair Hearings

If your Alabama Medicaid coverage was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is decided.1 In Alabama, you request that hearing directly from the Alabama Medicaid Agency, and a written request must be received within 60 days of the date the notice of action is mailed.2 If you act before your benefits stop, they can continue until a hearing decision is issued.3

In This Guide

• What You Can Appeal in Alabama Medicaid
• The Deadlines That Decide Your Alabama Medicaid Appeal
• How to Keep Your Benefits During the Appeal
• Managed Care in Alabama: Why There Is No Plan Appeal First
• How to Request an Alabama Medicaid Fair Hearing
• Frequently Asked Questions
• Learn More

What You Can Appeal in Alabama Medicaid

Federal law guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires Alabama's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted upon with reasonable promptness, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.1

In Alabama, the fair hearing right reaches any agency action or policy affecting your receipt of medical assistance. That includes:

• A denial of your application for Medicaid coverage
• A termination or reduction of your eligibility or a covered service
• A denial of payment for a service you received
• A prior authorization or level of care determination you disagree with
• A claim that was not acted upon with reasonable promptness

One limit is worth knowing up front. Alabama Medicaid eligibility is often based on determinations made by another agency, such as the Department of Human Resources (DHR) or the Social Security Administration (SSA). When your complaint concerns one of those underlying eligibility determinations, Alabama refers the matter to the agency that made the determination for a hearing rather than deciding it inside the Medicaid Agency.2

The Deadlines That Decide Your Alabama Medicaid Appeal

Two windows decide most Alabama Medicaid appeals, and they are not the same number: you have 60 days to request a fair hearing, but only 10 days to keep your benefits flowing while it is decided.

Under the Alabama Medicaid Administrative Code (560-X-3-.03), a written request for a fair hearing must be received by Medicaid within 60 days from the date the notice of action is mailed, and the agency will not accept requests filed outside that limit.2 Federal law caps this window at 90 days from the mailing date and lets a state set a shorter operational deadline, which is what Alabama's 60-day rule does.2 The date that governs you is the mailing date printed on your own notice, so read it off the notice rather than assuming 90 days.

If you want your benefits to keep flowing while the appeal is decided, a much shorter deadline applies: your fair hearing request must reach the Alabama Medicaid Agency within 10 days of the notice date, not the full 60 days. The next section explains how that continuation works.

Once your case is filed, Alabama also runs a clock on itself. Final administrative action on a fair hearing is to be taken within 60 days of the hearing request, and in any event within 90 days of the request.2

One separate rule can spare you an appeal entirely. If your coverage ended only because you did not return a renewal form or requested information on time, federal law requires the agency to reconsider your eligibility without a new application if you submit what was missing within 90 days after the termination date.4 That is a reconsideration, not a fair hearing, and it does not require you to argue the agency was wrong.

How to Keep Your Benefits During the Appeal

Keeping your benefits during an appeal is called aid paid pending, and in Alabama it turns on acting within the 10-day window rather than the 60-day one.

Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request a hearing before the date the action takes effect, the agency may not terminate or reduce your services until a decision is rendered after the hearing.3 The exception is when the only issue is one of federal or state law or policy rather than the facts of your case.

Alabama implements that federal rule through a 10-day instruction. In a case where Medicaid is terminating your eligibility, if your fair hearing request is received within 10 days of the date of the notice of action, your benefits may be continued pending the outcome of the hearing, unless you cause unnecessary delay in finishing it.2

When a termination or reduction notice arrives, do not wait out the full 60-day appeal window if you need your coverage to continue. Put your hearing request in writing and get it to the Alabama Medicaid Agency within 10 days of the notice date. Continuation is not automatic, so ask for it when you file.

Managed Care in Alabama: Why There Is No Plan Appeal First

In many states, a Medicaid member who is denied a service has to appeal to a private managed care organization (MCO) first and exhaust that internal appeal before reaching a state fair hearing. Alabama works differently.

Alabama does not deliver Medicaid benefits through risk-based managed care organizations. Its managed care programs run on the Primary Care Case Management Entity (PCCM-E) model instead. The Alabama Coordinated Health Network (ACHN) serves the general population, and the Integrated Care Network (ICN) provides enhanced case management to most long-term-care recipients in home and community-based services (HCBS) and institutional settings, including nursing facility stays over 60 days, the Elderly and Disabled Waiver, and the Alabama Community Transition Waiver.2

Because these networks are care-management entities rather than risk-based plans, there is no plan-level internal appeal to exhaust before a fair hearing. When you disagree with an agency action, you request the fair hearing directly from the Alabama Medicaid Agency under the Administrative Code's fair hearing chapter.2 That makes the Alabama path shorter than the two-step process used in risk-based managed care states: one request, to one agency.

How to Request an Alabama Medicaid Fair Hearing

You request a fair hearing by asking for one in writing. The written request, from you or your authorized representative, must be received by the Alabama Medicaid Agency within the 60-day window, and it should identify the action you are challenging.2 To reach the agency, start from its official site at medicaid.alabama.gov.

Once the agency has your request, it decides your case one of two ways. A face-to-face hearing is held before an impartial state hearing officer, or a documentary hearing is decided on the written record you and the agency submit.2 The Hearing Authority for all recipient fair hearings is the Commissioner of the Alabama Medicaid Agency, who appoints one or more impartial hearing officers to conduct the hearing and recommend a decision. A hearing officer who was involved in the action you are challenging cannot decide your case.2

If the final decision goes against you, it is not necessarily the end. An adverse decision approved by the Commissioner states that a rehearing or judicial review is available under the Alabama Administrative Procedure Act (APA).2

Learn More

Find personalized help navigating an Alabama Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.