Florida Medicaid Appeals and Fair Hearings: How to Appeal

If your Florida Medicaid was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits during the appeal.1 Florida splits the work of a Florida Medicaid appeal between two agencies. The Agency for Health Care Administration (AHCA) handles most Medicaid Fair Hearings, including denials by your managed care plan, and the Department of Children and Families (DCF) handles appeals of eligibility decisions it made. Your written notice tells you which office to file with.2

In This Guide

• What You Can Appeal in Florida Medicaid
• The Deadlines That Decide Your Florida Medicaid Appeal
• How to Keep Your Benefits During a Florida Medicaid Appeal
• Managed Care (SMMC) Appeals: Appeal Your Plan First
• How to Request a Fair Hearing in Florida
• What Happens at the Hearing
• Frequently Asked Questions

What You Can Appeal in Florida Medicaid

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 (42 USC 1396a(a)(3)) requires Florida's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted upon promptly, and 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.1

In Florida, that means you can appeal:

• A denial of your Medicaid application (income, assets, or documentation)
• A termination of your eligibility or a reduction of a service you already receive
• A denial, reduction, suspension, or termination of a Medicaid service by AHCA or by your SMMC plan
• A prior authorization denial or a level-of-care determination
• AHCA's denial of a For Cause request to change managed care plans

The right reaches across the program, from the eligibility decision that starts your coverage to the service authorizations that keep it working. Which office hears your appeal depends on who made the decision, and your written notice of hearing rights states which one is responsible.2

The Deadlines That Decide Your Florida Medicaid Appeal

Two windows matter most in a Florida Medicaid appeal, and they are not the same number.

The request window runs up to 90 days, and no further. 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. That 90 days is a ceiling on what a state may allow, not a floor you are entitled to. A state may set a shorter window so long as it stays reasonable, and a shorter state deadline is fully enforceable against you.3 So the deadline that governs your case is the one printed on your notice of action. Read it there, and do not assume you have the full 90 days.

The continuation window closes earlier, before the date of action on your notice. It decides whether your benefits keep flowing while the appeal is pending, and it is covered in the next section.

If your Medicaid ended only because you did not return a renewal form or requested information on time, a separate rule can help. 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 DCF whether Florida does.6

How to Keep Your Benefits During a Florida Medicaid Appeal

Continuation of benefits (often called "aid paid pending") is not automatic, and you have to ask for it in time.

Under the federal rule at 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date of action stated on that notice, it may not reduce or terminate your services until a decision is rendered after the hearing.4 The trigger is the date of action, not a flat count of days after you got the letter.

Two limits shape that rule. It protects a benefit you already hold, so it does not reach the denial of an initial application, where there is no service to continue. And it depends on the agency having sent the required 10-day (or 5-day) advance notice, and it does not apply when the sole issue is one of federal or state law or policy. Miss the date of action and continuation is not triggered, but a request made not more than 10 days after that date lets the agency reinstate services under 42 CFR 431.231.4

In Florida, a beneficiary whose existing service is scheduled to be reduced, suspended, or terminated has the right to keep those services until a final hearing decision, but must request that continuation during the intake process when the hearing is set up.2 Put the request in writing and make it when you file, not later.

If your services continue and the hearing decision is not in your favor, Florida may ask you to pay for the cost of the services that were furnished only because benefits were continued.2 The federal rule sets the outer edge of that bill: under 42 CFR 431.230(b), the agency may recover only the cost of services furnished solely by reason of the continuation, not everything it paid while the appeal was pending.4 That is the tradeoff to weigh: continuation protects your care during the fight, but a loss can carry a bill.

Managed Care (SMMC) Appeals: Appeal Your Plan First

Most Florida Medicaid members get their care through a Statewide Medicaid Managed Care (SMMC) plan, a Managed Care Organization (MCO) under contract with AHCA. When your plan denies care, you appeal to the plan before you can reach a state fair hearing.2 These rules come from the federal managed care regulations at 42 CFR Part 438.

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 service it already approved, a denial of payment, or a failure to act within required timeframes. That notice must tell you how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue.7

You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, and you can request it orally or in writing.5 The plan has only one level of appeal, and you must finish it before requesting a state fair hearing. Going straight to a fair hearing without exhausting the plan appeal gets the request dismissed.

A Florida Statewide Medicaid Managed Care (SMMC) plan must resolve a standard internal 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 ask for the extension or the plan shows the state that more information is needed and the delay is in your interest.8 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or your ability to regain function.

Once the plan resolves the appeal against you, the state must give you no fewer than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing, with the exact number within that band set by the state.8 A Florida SMMC fair hearing is filed with AHCA.2

To start a plan appeal, call your plan's member services line. Florida's active SMMC plans and their member-services numbers are below.9

Not sure which plan you have or which serves your county? See our guide to Florida Medicaid managed care plans.

How to Request a Fair Hearing in Florida

Your notice of hearing rights states whether AHCA or DCF is responsible, so start there.2

Most Medicaid Fair Hearing requests are filed with AHCA (the Agency for Health Care Administration), including the denial, reduction, suspension, or termination of a Medicaid service by AHCA or by your SMMC plan, and AHCA's denial of a For Cause plan-change request. AHCA's Medicaid Hearing Unit takes intake at P.O. Box 7237, Tallahassee, FL 32314-7237, by phone at 1-877-254-1055 (toll-free), by fax at 1-239-338-2642, or by email at MedicaidHearingUnit@ahca.myflorida.com. AHCA's Office of Fair Hearings (2727 Mahan Drive, MS#11, Tallahassee, FL 32308; 1-850-412-3649) then acknowledges the request and assigns a Hearing Officer, who schedules the hearing under Rule 59G-1.100 of the Florida Administrative Code (F.A.C.).2

Actions the Department of Children and Families (DCF) takes on your Medicaid eligibility (as well as SNAP and Temporary Cash Assistance) are appealed to DCF's Office of Appeal Hearings. You can request a hearing in writing by mail or email, by phone, or through DCF's online form. Mail the Appeal Hearings Section at 2415 North Monroe Street, Suite 400-I, Tallahassee, FL 32303-4190; email appeal.hearings@myflfamilies.com; or call 1-850-488-1429.2

A DCF eligibility decision arrives as a Notice of Case Action. It states the pathway and rule that was applied, the reason for the denial (for example "exceeds asset limit," "verifications not returned," or "transfer of assets penalty"), your right to appeal, the deadline to request a hearing, and where to file. If it is unclear, ask for the case file in writing right away, because the agency must produce it before the hearing. Your request itself can be a single sentence: "I am appealing the denial of [pathway] for [name and case number] dated [date]. I disagree with the decision."

Whichever office hears your case, request the hearing before the date of action on your notice and ask for continuation in writing if you want your benefits to keep flowing while you wait.

What Happens at the Hearing

A DCF hearing officer usually holds an eligibility hearing by phone. You may bring witnesses and documents, be represented by an attorney, a relative, or a non-profit advocate, and question the agency's witness. The officer issues a written final order, and if you win, DCF must reverse the denial and issue back-coverage as appropriate. Florida law provides for judicial review in the state appellate courts if you disagree with the order. On the AHCA side, the Hearing Officer assigned by its Office of Fair Hearings schedules the hearing under Rule 59G-1.100, F.A.C.2

Learn More

Find personalized help navigating a Florida 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.