Connecticut Medicaid Appeals and Fair Hearings

If your Connecticut Medicaid (HUSKY Health) 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 Connecticut generally gives you 60 days from the date on your notice to ask for that hearing, and if you ask before the change takes effect, your coverage can continue until a hearing officer rules.2

In This Guide

• What You Can Appeal in Connecticut Medicaid
• The Deadlines That Decide Your Connecticut Medicaid Appeal
• How to Keep Your Benefits During the Appeal
• Managed Care and Your Appeal in Connecticut
• How to Request a Fair Hearing in Connecticut
• Frequently Asked Questions
• Learn More

What You Can Appeal in Connecticut Medicaid

Federal law gives Medicaid applicants and beneficiaries the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act requires each state plan to offer a hearing to anyone whose claim for medical assistance is denied or is not acted on promptly, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted in error, denied a claim for eligibility or for covered services, issued a determination of their liability, or did not act on a claim promptly. It also covers a nursing-facility resident who believes the facility wrongly decided they must be transferred or discharged. The right has one stated limit: the agency need not grant a hearing when the only issue is a federal or state law that requires an automatic change affecting some or all beneficiaries.1

In Connecticut, that right is administered by the Department of Social Services (DSS), which runs Medicaid under the HUSKY Health name. You can request a fair hearing when DSS takes an action that:

• Denies your application for coverage
• Terminates or reduces coverage you already have
• Reduces the hours or amount of a service you were receiving
• Denies a service, including through a prior authorization decision

The right reaches across the program, not just applications. If a DSS Notice of Action tells you that something is being denied, cut, or ended, that notice is the trigger for your appeal, and it carries the date your deadlines run from.2

The Deadlines That Decide Your Connecticut Medicaid Appeal

Two deadlines govern a Connecticut Medicaid appeal, and they are not the same date.

The first is the request window. For Connecticut Medicaid, the hearing request generally must be made within 60 days from the date of the DSS Notice of Action.2 Federal law sets a ceiling of 90 days from the date the notice is mailed, and a state is allowed to use a shorter operational window below that ceiling, which is what Connecticut's 60-day rule does.2 Do not assume you have 90 days: the deadline that generally governs you is 60 days from the date printed on your Connecticut notice.

A nursing-home transfer or discharge runs on its own, shorter clock. If a nursing facility fails to readmit a resident, the resident has 20 days from receiving the facility's notice to request a hearing. For an involuntary transfer or discharge, the resident has 60 days from the date the facility issues the notice, but to stop the transfer or discharge from going ahead while the hearing is pending, the request must be made within 20 days of receiving the notice. A resident who waits for the 60-day mark keeps the hearing but loses the right to stay in the facility while it happens.2

The second is the continuation window, which falls before the date of action. It is a separate and earlier deadline, and it is the one that keeps your benefits flowing while you appeal. It is covered in the next section.

One more protection applies to renewals. If your coverage was ended only because you did not return a renewal form or requested information on time, you do not always have to reapply. Under 42 CFR 435.916, if your eligibility is based on modified adjusted gross income (MAGI) and you submit the renewal form within 90 days after the termination date, the agency must reconsider your eligibility without a new application. If you qualify through SSI or another pathway that needs no income determination, or through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Connecticut may offer that same 90-day reconsideration but federal law does not require it, so ask DSS.3

How to Keep Your Benefits During the Appeal

Keeping your coverage during an appeal is called aid paid pending, and in Connecticut it is more generous for Medicaid than for other benefits.

For Medicaid (HUSKY), your benefits may continue if you make the hearing request any time before the date of the proposed action shown on your notice.2 That is a wider window than the one DSS applies to its other programs, which generally require the request within 10 days of the notice.2

This continuation right comes from 42 CFR 431.230(a): when the agency sends the required advance notice and you request the hearing before the date of action, it may not terminate or reduce your services until a decision is rendered after the hearing. That protection gives way only if the hearing determines the sole issue is one of federal or state law or policy and the agency promptly tells you in writing that services will be cut pending the decision; both must happen.4 The trigger is the date of action on the notice, not the day it reached your mailbox.

If services were cut without the required advance notice, federal rules go further: the agency must reinstate them until a hearing decision if you request a 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 agency determines the action resulted from something other than applying federal or state law or policy. Not every cut without advance notice qualifies: the rules let the agency give notice as late as the date of action in some cases, such as admission to an institution where you are ineligible for further services or a change in level of care your doctor prescribed. If that is your situation, don't count on mandatory reinstatement; the agency may still reinstate services if you request a hearing no more than 10 days after the date of action. One cost to weigh: if the hearing upholds the agency's action, federal rules let the agency recover the cost of services furnished only because of the continuation.4

The practical takeaway: when an adverse-action notice arrives, find the date of the proposed action on it and request your hearing before that date. Ask in writing, and act early, because the continuation deadline can come well before the 60-day deadline to request the hearing itself.

Managed Care and Your Appeal in Connecticut

In states that use private health plans, a Medicaid member who is denied a service by a private managed care organization (MCO) must first appeal to that plan and receive its notice upholding the denial before a state fair hearing is available, unless the plan misses its federal notice and timing requirements, in which case the member is deemed to have exhausted the plan appeal.5 Connecticut works differently.

DSS states that as of January 1, 2011, all HUSKY Health services are coordinated by a single statewide Administrative Services Organization (ASO), and that Community Health Network of Connecticut was chosen as that ASO. That is a single administrative organization rather than a roster of competing health plans.2 Neither the DSS hearing pages nor the HUSKY ASO page names any plan-level internal appeal you must exhaust before your hearing.

What this means for you is simpler than in a managed care state: the hearing request described on the DSS hearing pages goes to DSS itself. Read the Notice of Action you received, because it carries the instructions for the decision it announces.2

How to Request a Fair Hearing in Connecticut

Connecticut Medicaid fair hearings are handled by the DSS Office of Legal Counsel, Regulations and Administrative Hearings (OLCRAH), the unit within DSS that hears these appeals.2

The best way to request a hearing is to use the Hearing Request Form that is attached to your DSS Notice of Action. If that is not possible, a letter to the hearing office that is signed by the applicant or recipient and explains why a hearing is requested is also accepted. The letter should include the person's name, address, identification number, and which program decision is being appealed.2

Requests go to the Office of Legal Counsel, Regulations and Administrative Hearings, 55 Farmington Avenue, 11th floor, Hartford, CT 06105. The Administrative Hearings main telephone number is 860-424-5760, or 1-800-462-0134 outside the Hartford calling area (that number is toll free only within Connecticut).2

After you file, DSS generally schedules the hearing to take place within 30 days of receiving your request, and the hearing officer generally issues the final decision no later than 90 days after DSS receives the hearing request.2

Learn More

Find personalized help navigating a Connecticut 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.