Delaware Medicaid Appeals and Fair Hearings: Keep Your Benefits

If your Delaware Medicaid coverage is denied, reduced, or terminated, you have 90 days from the date on your notice to request a fair hearing.1 File before the action takes effect and your benefits continue unchanged while you wait for a decision. Every Medicaid applicant and beneficiary has this right to appeal under federal law.2 A Delaware Medicaid appeal is heard by a Hearing Officer in the Division of Social Services (DSS), part of the Delaware Department of Health and Social Services (DHSS), and that officer's decision is the final decision of DHSS.1

In This Guide

• What a Delaware Medicaid Appeal Can Challenge
• What Are the Delaware Medicaid Appeal Deadlines?
• How to Keep Your Benefits During the Appeal (Aid Paid Pending)
• If You're in a Managed Care Plan, Appeal to the Plan First
• How to Request a Delaware Medicaid Fair Hearing
• Frequently Asked Questions
• Learn More

What a Delaware Medicaid Appeal Can Challenge

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 Delaware 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.2 In Delaware, a Medicaid decision you can appeal comes from the Division of Medicaid and Medical Assistance (DMMA) or the Division of Social Services (DSS), and your fair hearing is held by a DSS Hearing Officer. The right covers any DHSS decision to deny, reduce, suspend, delay, or terminate your benefits.1

You can request a fair hearing to challenge:

• An application denial based on income, assets, household size, or documentation
• A reduction, suspension, or termination of your eligibility or a covered service
• A renewal or recertification that was denied or closed
• A delay in acting on your claim
• Your managed care plan's denial, reduction, suspension, or termination of a service

Because federal rules let you keep your Medicaid while an appeal is pending when you request the hearing in time, a current recipient facing a cut or termination does not lose coverage simply for appealing.4

What Are the Delaware Medicaid Appeal Deadlines?

A Delaware Medicaid appeal runs on several deadlines, and they are not the same number. The one that ends your right to a hearing is different from the earlier one that keeps your benefits flowing, and managed care adds its own two windows.

The window to request a Delaware Medicaid fair hearing is 90 days from the date your notice of action is mailed.1 That number comes from a federal cap, not a federal guarantee: 42 CFR 431.221(d) requires a state to allow a reasonable time not to exceed 90 days from the mailing date, so 90 days is the most a state may give and some states give less. Delaware gives the full 90, and the date printed on your notice is what starts the clock.3

The continuation window is earlier, and it is the one that keeps your benefits flowing. To keep your benefits during the appeal, you have to request the hearing before the action's effective date. The next section covers how that works.

Managed care adds two windows. If your denial came from your health plan, you first file the plan's internal appeal within 60 calendar days of the plan's notice, and then, once the plan upholds its decision, you have 120 calendar days from the plan's resolution notice to request a fair hearing.1

Two more deadlines sit on the other side of the hearing. The Hearing Officer must issue a final decision within 90 days of the date you file your appeal, and if you disagree with that decision, you can ask the Delaware Superior Court for judicial review within 30 days.1

How to Keep Your Benefits During the Appeal (Aid Paid Pending)

Continued benefits during an appeal, often called aid paid pending, turn on timing. In Delaware, if you request your fair hearing before the effective date of the action, your services may not be terminated or reduced until the Hearing Officer decides your case, and DSS provides those continued benefits within 5 working days of the date it receives your request.1

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.4 The trigger is the action date printed on your notice, not a flat count from the day you opened the envelope.

Two practical points follow:

• It is not automatic. You have to request the hearing in time. Read the effective date off your notice of action and file before it.
• You may owe the money back if you lose. Under 42 CFR 431.230(b), when benefits continue during the appeal and the agency's action is later upheld, the agency may recover the cost of the services it furnished solely because your benefits kept flowing.4

If You're in a Managed Care Plan, Appeal to the Plan First

If your care comes through one of Delaware Medicaid's managed care organizations (MCOs), the order of steps changes. Delaware's three participating plans are AmeriHealth Caritas, Delaware First Health, and Highmark Health Options.1 When one of these plans denies, reduces, or ends a service, you appeal to the plan before you can reach a state fair hearing.1

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, and that notice must explain the decision and its reasons, how to appeal and reach a fair hearing, and how to ask that your benefits continue during the appeal.5

You then file the plan's internal appeal, which is the required first step. You have 60 calendar days from the date on the plan's notice to file, and you can request it orally or in writing.6 Delaware's plans have one level of appeal, and you must complete it before you request a fair hearing.1

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.7 If waiting the standard timeline could put your health at serious risk, ask the plan for the expedited 72-hour track and follow the instructions on your plan's notice for requesting it.

After the plan decides, the fair hearing becomes available. If the plan upholds its denial, you have 120 calendar days from the date of its written resolution to request a fair hearing.1 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, and Delaware uses the full 120.7 If the plan misses the notice and timing rules of 42 CFR 438.408, your appeal is deemed exhausted and you may go straight to a fair hearing.1

How to Request a Delaware Medicaid Fair Hearing

Fee-for-service members can request a fair hearing directly; managed care members request it after finishing the plan's appeal. Either way, the request goes to DSS, and a DSS Hearing Officer, whose decision is the final decision of DHSS, hears the case.1

Start with the notice you received. Your notice letter carries the instructions for requesting a hearing, and DHSS must let you submit a Medical Assistance hearing request online through the state website, by phone, by mail, in person, or through other commonly available electronic means.1 Whichever method you use, file before the action's effective date if you want your benefits to continue, and keep a copy of the notice you are appealing.

If your Delaware Medicaid closed only because you missed renewal paperwork, you may not need a hearing at all. Under 42 CFR 435.916, if your eligibility is based on MAGI income rules and your coverage was terminated only because you did not return a renewal form or requested information on time, the agency must reconsider your eligibility without a new application when you submit the renewal form within 90 days after the termination date. If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, federal law lets a state offer that same 90-day reconsideration but does not require it, so ask DSS whether Delaware does.8

Learn More

Find personalized help navigating a Delaware 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.