District of Columbia Medicaid Appeals: Keep Your Benefits

In the District of Columbia, you have 90 days from the postmark on your Medicaid denial notice to request a fair hearing, and you can often keep your benefits while you appeal.1 Whether your coverage was denied, cut, or terminated, you make that request to the DC Office of Administrative Hearings (OAH), an independent agency separate from the Medicaid office that made the decision.1 Federal law guarantees this right to a fair hearing, and if your care runs through a managed care plan, you appeal to the plan first, then take an unresolved denial to OAH.2

In This Guide

• What a District of Columbia Medicaid Appeal Covers
• District of Columbia Medicaid Appeal Deadlines That Decide Your Case
• How to Keep Your Benefits During the Appeal
• Managed Care Appeals: Appeal Your Health Plan First
• How to Request a District of Columbia Medicaid Fair Hearing
• Frequently Asked Questions
• Learn More

What a District of Columbia Medicaid Appeal Covers

Federal Medicaid law guarantees every applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act requires the District's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted on promptly, and 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.2

In the District, you can request a fair hearing when the DC government or a Medicaid provider takes an adverse action against your eligibility, coverage, or a service.1 That includes:

• A denial of your Medicaid application
• A termination or reduction of eligibility or a covered service
• A suspension or stop of a service or item you were receiving
• A prior-authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service

The DC Office of Administrative Hearings (OAH) hears these cases, and it is an agency independent of the Medicaid agency itself, the Department of Health Care Finance (DHCF).1 The office deciding your appeal is not the office that made the decision you are challenging.

District of Columbia Medicaid Appeal Deadlines That Decide Your Case

Three separate windows govern a District of Columbia Medicaid appeal, and they carry different numbers.

The first is the request window. You may request a fair hearing no more than 90 days from the postmark date on the notice telling you of the action.1 That 90 days is a federal ceiling, not a federal guarantee: 42 CFR 431.221 requires a state to allow a reasonable time to request a hearing, "not to exceed 90 days" from the date the notice is mailed, so a state that sets a shorter window can enforce it. The District allows the full 90, which is why the date on your own notice is the one that governs.1 Read that date off the notice, and count from the postmark, not the day it reached your mailbox.

The second is the continuation window, which runs to the end of the advance-notice period and decides whether your benefits keep flowing while the appeal is pending. It is covered in the next section.

The third applies only to managed care. If your denial came from a managed care plan, you have 60 calendar days from the date on the plan's adverse benefit determination notice to file the plan's internal appeal.4 After the plan resolves that appeal against you, the District must give you no less than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request an OAH fair hearing.5

One more protection applies to renewals. If your coverage 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 your eligibility is based on MAGI income rules 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 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 DHCF whether the District does.6

How to Keep Your Benefits During the Appeal

Keeping your benefits during an appeal is often called "aid paid pending," and it is not automatic. You have to request the hearing in time and ask for the benefit to continue.

In the District, you have the right to keep receiving a benefit while your fair hearing is being reviewed, but to do so you must request the hearing before the 30-day notice period ends.1 In practice that means acting on the notice quickly rather than waiting out the full 90-day appeal window.

The federal rule behind that protection is 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, the agency may not terminate or reduce 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 effective date of the action, not the longer window you have to file the appeal itself. A request made after the action has already taken effect does not continue your benefits under that rule.3

The practical takeaway: when an adverse-action notice arrives, find the date the action takes effect, request the hearing before that date, and ask in writing that your benefits continue. If you wait, you can still appeal within the 90-day window, but your services may stop in the meantime.

Managed Care Appeals: Appeal Your Health Plan First

Many District residents get their Medicaid care through a managed care plan, which federal rules call a managed care organization (MCO). The District contracts with three managed care plans for its general Medicaid programs: Wellpoint DC, AmeriHealth Caritas DC, and MedStar Family Choice DC, which serve the DC Healthy Families Program, the DC Health Care Alliance, and the Immigrants Children's Program. Health Services for Children with Special Needs (HSCSN) serves the separate Child and Adolescent Supplemental Security Income (SSI) Program.1 When your plan denies care, you appeal to the plan before you reach an OAH fair hearing.1

Under 42 CFR 438.404, the plan must give you timely, written notice of an adverse benefit determination. That notice must state the determination and the reasons for it, tell you how to appeal and how to exhaust the plan's single level of appeal before requesting a state fair hearing, explain when an appeal can be expedited and how to request it, and explain your right to have benefits continue during the appeal and how to request continuation.7

The internal appeal comes next. You have 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.4 A plan has only one level of appeal, and you must exhaust it before requesting an OAH fair hearing.5

The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours. Either timeframe can be extended by up to 14 calendar days if you request the extension, or if the plan shows the District that more information is needed and the delay is in your interest.5 Request the expedited track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function.8

Once the plan rules against you, or if it fails to meet the notice and timing rules, you may request an OAH fair hearing, and you have 90 to 120 days from the plan's notice of resolution to do it.5

How to Request a District of Columbia Medicaid Fair Hearing

You request a District of Columbia Medicaid fair hearing from the DC Office of Administrative Hearings, not from DHCF. You can file in writing, in person, or by phone, and OAH also offers an online e-filing portal.1 To file by phone, call OAH at 202-442-9094; from the main menu, press "3" for a case filing, then "3" again for public benefits.1 OAH is located at 441 4th Street NW, Suite 450 North, Washington, DC 20001.1

Whatever method you choose, do two things in the same request: file before the 90-day deadline on your notice, and, if you want your benefits to continue, ask for continuation before the advance-notice period ends.1 For a managed care denial, complete your plan's internal appeal first, then bring an unresolved denial to OAH.5

Learn More

Find personalized help navigating a District of Columbia 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.