California Medicaid Appeals and Fair Hearings

If your California Medi-Cal coverage is denied, reduced, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits during the appeal.1 A California Medicaid appeal (Medi-Cal is California's Medicaid program) is decided by the California Department of Social Services (CDSS) State Hearings Division through a State Hearing before an impartial administrative law judge who works for the state, not for your county or your health plan.2 You must request that hearing within 90 days of the date you receive your Notice of Action, and if you file before the action takes effect, your benefits continue unchanged during the appeal.2

In This Guide

• What you can appeal in California Medicaid
• California Medicaid appeal deadlines that decide your case
• How to keep your benefits during the appeal (Aid Paid Pending)
• Managed care appeals: exhaust your plan first
• How to request a California Medicaid fair hearing

What you can appeal in California 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)) and the implementing regulation at 42 CFR 431.220 require California to grant a hearing to anyone whose claim for medical assistance is denied, is not acted on with reasonable promptness, or who believes the agency took an erroneous or adverse action.1 In California, that hearing is the Medi-Cal State Hearing, and the right reaches across the program.

You can request a State Hearing to challenge:

• An application denial (income, assets, household size, or citizenship and identity documentation)
• A termination or reduction of your eligibility or a covered service
• A renewal or recertification denial
• A prior authorization denial or a change in your level of care
• A managed care plan's denial, reduction, suspension, or termination of a service

This right reaches across each of these situations. Because federal rules let you keep your Medi-Cal while an appeal is pending when you request the hearing in time, an existing recipient facing a cut or termination does not lose coverage just for appealing.3

California Medicaid appeal deadlines that decide your case

Three windows govern a California Medicaid appeal, and they are not the same number: the deadline to request a State Hearing, the earlier deadline that keeps your benefits flowing, and a separate deadline for managed care denials.

The request window is 90 days. You must file your request for a State Hearing within 90 days of the date you receive your Notice of Action.2 This tracks the federal ceiling at 42 CFR 431.221(d), which allows a reasonable time not to exceed 90 days from the date the notice is mailed.2 A late request may still be accepted for good cause, such as illness or disability that kept you from filing on time.2

The continuation window runs to the date the action takes effect. This is the earlier deadline, and it is the one that keeps your benefits flowing during the appeal. The next section covers how it works.

The managed care window is 120 days from the plan's decision. If your denial came from a Medi-Cal managed care plan, you first complete the plan's internal appeal, and then you have 120 calendar days from the date of the plan's written appeal decision to request a State Hearing.2 Federal managed care rules set that window at no fewer than 90 and no more than 120 days from the plan's notice of resolution; California uses the full 120.4

One more federal deadline protects renewals. If your Medi-Cal was terminated only because you did not return a renewal form or requested information on time, you do not always have to appeal or reapply: under 42 CFR 435.916, if you submit the form or the missing information within 90 days after the termination date, the agency must reconsider your eligibility without a new application.5

How to keep your benefits during the appeal (Aid Paid Pending)

Aid Paid Pending keeps your benefits flowing during the appeal, and it turns on timing. In California, if you request your State Hearing by the effective date of the action (when a 10-day advance notice is required), or otherwise within 10 days of the date of the notice, your benefits continue unchanged during the appeal.2 California calls this Aid Paid Pending.

The rule comes from federal law. Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date the action takes effect, it may not reduce or terminate your services until a decision is rendered after the hearing, unless the only issue is one of law or policy.3 The trigger is the action date on your notice, not a flat count from when you opened the envelope.

Two practical points follow:

• Not automatic: You have to request the hearing in time. Read the effective date off your Notice of Action and file before it.
• Recoupment if you lose: Under 42 CFR 431.230(b), when benefits are continued and the agency's action is later upheld, the agency may recover the cost of the services furnished solely because your benefits kept flowing.3 The notice has to warn you of that risk for recoupment to apply.

Managed care appeals: exhaust your plan first

Most Medi-Cal members receive care through a Medi-Cal managed care plan, also called a managed care organization (MCO), rather than fee-for-service, and that changes the order of steps.2 If your denial came from a plan such as CalOptima, Health Net Community Solutions, Molina Healthcare of California, or another plan in California's Medi-Cal managed care plan roster, you appeal to the plan before you reach a State Hearing.6

Your plan must first tell you what it decided. Under 42 CFR 438.404, the plan must give you timely written notice of an adverse benefit determination, which includes a denial or limited authorization of a service, a reduction or termination of a previously authorized service, a denial of payment, or a failure to act within required timeframes. That notice must tell you how to appeal and how to ask that your benefits continue.7

You then file the plan's internal appeal and must complete it before a State Hearing. Federal rules give you 60 calendar days from the date on the determination notice to file the plan's internal appeal, which you can request orally or in writing.8 The plan has one level of appeal, and you must complete it before requesting a State Hearing. In California, the plan reviews your appeal and sends you a written decision within 30 days.2

The plan also faces deadlines to decide. A standard appeal must be resolved within 30 calendar days and an expedited appeal within 72 hours, either of which the plan can extend by up to 14 calendar days if you ask or if the plan shows the state that more information is needed and the delay is in your interest.4 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

After the plan decides, the State Hearing becomes available. If the plan upholds its denial, you then have 120 calendar days from the date of its written decision to request a State Hearing.2 If the plan fails to meet the notice and timing rules, the appeal is deemed exhausted and you may go straight to a State Hearing.7

How to request a California Medicaid fair hearing

Fee-for-service members can request a State Hearing directly within the 90-day window; managed care members request it after finishing the plan's appeal.2 Either way, you file with the California Department of Social Services State Hearings Division, and an administrative law judge (ALJ) who works for CDSS, not for your county or your plan, decides the case.2

You can request the hearing in any of these ways:

• Online through the Appeals Case Management System (ACMS) at acms.dss.ca.gov
• By phone at (800) 743-8525 (TDD (800) 952-8349)
• By mail to the CDSS State Hearings Division, P.O. Box 944243, Sacramento, CA 94244-2430
• By fax to (833) 281-0905
• On paper, by completing the "Request for State Hearing" on the back of your Notice of Action

The State Hearings Division cannot accept a hearing request by email.2 Whichever method you use, put your request in before the action's effective date if you want Aid Paid Pending, and keep a copy of the notice you are appealing.

Learn More

Find personalized help navigating a California Medi-Cal 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.