How to Appeal a Medicaid Denial: Fair Hearing Rights (2026)

A Medicaid denial is not the final word. You can appeal, and one deadline decides whether your benefits keep flowing while you wait: to keep your current coverage during the appeal, you usually have to request the hearing before the date your coverage is set to change.1 This guide covers how to appeal a Medicaid denial, from your federal fair-hearing rights and the two deadlines that decide your case to exactly how to act.

In This Guide

• You Have the Right to Appeal
• The Two Deadlines That Matter
• Keeping Your Benefits During the Appeal
• If You're in a Managed-Care Plan
• How to Request a Fair Hearing
• Frequently Asked Questions
• Learn More

You Have the Right to Appeal

Federal law gives you a right to a fair hearing. Under Section 1902(a)(3) of the Social Security Act and 42 CFR 431.220, applicants and beneficiaries have the right to a hearing before the state agency if their claim for eligibility or covered services is denied, or if the agency doesn't act on it with reasonable promptness. The one case the regulation carves out: the agency need not grant a hearing when the sole issue is a federal or state law requiring an automatic change that adversely affects some or all beneficiaries.2 You do not have to do it alone: once you designate an authorized representative, such as a family member, an advocate, or a lawyer, that person can request the hearing and act on your behalf, and a power of attorney or court-ordered guardianship you already have counts as that designation.5

This applies to more than an outright denial. You can appeal a termination of coverage, a reduction in services, or a decision you believe the agency got wrong.

The Two Deadlines That Matter

The single most common mistake is confusing two different deadlines. They are not the same, and mixing them up can cost you your benefits.

Deadline 1 is the window to request the hearing at all. Under 42 CFR 431.221(d), the state must give you a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a fair hearing.3 90 days is the federal ceiling, not a guaranteed minimum; a state may set a shorter window, so check the deadline printed on your notice.

Deadline 2 decides whether your benefits keep flowing while you appeal. To keep your current coverage during the appeal, you generally have to request the hearing before the date of action listed on your notice.1 Miss that earlier date and you can still appeal, but your benefits may stop while the appeal is pending.

The next section explains Deadline 2 in detail, because it is where the whole outcome can turn.

Keeping Your Benefits During the Appeal

This continuation of benefits is called "aid paid pending," and the rule is specific. Under 42 CFR 431.230(a), if the agency sent the required advance notice (generally 10 days, sometimes 5) and you request the hearing before the date of action, the agency may not reduce or terminate your services until a decision is reached after the hearing.1 The one exception has two halves, and both must be met: it is determined at the hearing that the sole issue is a question of federal or state law or policy, and the agency promptly tells you in writing that services are to be terminated or reduced pending the decision.1

If you miss that date, you still have options. Under 42 CFR 431.231, if you request the hearing no more than 10 days after the date of action, the agency may reinstate your services, and once reinstated they continue until the hearing decision unless the sole issue is one of federal or state law or policy.1 If the agency acted without sending the required advance notice at all, reinstatement is not optional: it must reinstate your services and continue them until the hearing decision, as long as you request the hearing within 10 days of receiving the notice of action (counted as 5 days after the date on the notice unless you show it arrived later) and the action did not result from applying federal or state law or policy.1

There is a real trade-off to understand before you ask for aid paid pending. Under 42 CFR 431.230(b), if your appeal is later denied, the agency may recover the cost of the benefits it continued solely because of the appeal.1 So keeping benefits during the appeal protects you if you win, but can leave you owing money if you lose. Weigh that based on how strong your case is.

If You're in a Managed-Care Plan

If you get your Medicaid care through a managed-care plan (an MCO), the path is different: you appeal to the plan first, then to the state.

• The plan must send you written notice. Under 42 CFR 438.404, the plan must give timely, adequate written notice of any adverse benefit determination, including the reason and your appeal rights.6
• File the plan's internal appeal within 60 days. Under 42 CFR 438.402(c)(2)(ii), you have 60 calendar days from the date on the notice to file an appeal with the plan, and you can do it orally or in writing.4 If you have both Medicare and Medicaid and are enrolled in what federal rules call an applicable integrated plan, different plan-level appeal rules (42 CFR 422.629 through 422.634) apply instead of this 60-day rule.4
• The plan must decide on a clock. Under 42 CFR 438.408(b), the plan must resolve a standard appeal within a state timeframe no longer than 30 calendar days, or within 72 hours for an expedited appeal when your health requires speed; either can be extended by up to 14 calendar days.7
• Then you can go to the state. Under 42 CFR 438.408(f)(2), once the plan upholds its decision, the state must give you between 90 and 120 calendar days to request a state fair hearing.7
• If the plan mishandles your appeal, you can skip ahead. When the plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving your appeal, your appeal is deemed exhausted and you may go straight to a state fair hearing.7 This turns on how the plan handles the appeal, so file the plan's appeal within 60 days of the date on the notice either way.4

Aid paid pending applies in managed care too, but on clocks much shorter than the filing deadlines. To keep your services during the plan appeal, you must ask for continuation on or before the later of 10 calendar days after the plan sends its notice or the date the change is set to take effect.7 And if the plan upholds its decision, continued benefits end unless you request the state fair hearing and continuation within 10 calendar days after the plan sends that notice, so waiting out the full 90-to-120-day window can cost you your coverage in the meantime.7

If the plan's decision ends payment for a nursing-home stay, see what to do when a Medicaid plan stops paying for the nursing home, which walks through both appeals and their deadlines.

How to Request a Fair Hearing

Your denial or termination notice tells you how to request a hearing, usually by mail, phone, or an online portal, and it lists the deadline. To request one:

• Contact your state Medicaid agency using the method on your notice.
• Give your name, the notice, and a clear statement that you want a fair hearing.
• If you want to keep your benefits, say so, and do it before the date of action on the notice.
• Keep a copy of everything you send and the date you sent it.

After the hearing, the state issues a written decision. Timeframes vary, so ask your state agency how long its decision takes and when to expect it. If you win, the agency must correct its action; if you kept benefits during the appeal and lose, remember the agency may seek to recover that cost.

Learn More

Find personalized help understanding your Medicaid options 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.