Idaho Medicaid Appeals and Fair Hearings: How to Appeal

If your Idaho Medicaid coverage was denied, reduced, 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 In Idaho the deadline to ask for a hearing is shorter than the federal ceiling: 30 days from the date on your notice for most eligibility decisions, and 28 days for a Medicaid service decision.1

In This Guide

• What you can appeal in Idaho Medicaid
• The deadlines that decide your Idaho Medicaid appeal
• How to keep your benefits during an Idaho Medicaid appeal
• Managed care appeals: exhaust the plan first
• How to request an Idaho Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in Idaho 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)) requires the state plan to give a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness, and 42 CFR 431.220 extends that right to anyone who believes the agency acted in error or made an adverse determination.3

In Idaho, the agency is the Idaho Department of Health and Welfare (DHW). An applicant or recipient who disagrees with a DHW decision that denies, reduces, or terminates coverage or benefits has the right to appeal, which Idaho also calls a fair hearing.1 In practice, that means you can appeal:

• An application denial (income, assets, or documentation)
• A termination or reduction of eligibility or covered benefits
• A reduction in a service or in authorized hours, such as personal-care hours
• A prior-authorization denial or a level-of-care determination
• A developmental-disability service decision made by the Division of Medicaid
• A managed-care plan's denial, reduction, suspension, or termination of a service

The right reaches across the program, from the eligibility decision at your front door to the service decisions that follow.

The deadlines that decide your Idaho Medicaid appeal

Idaho sets two request windows, and both are shorter than the federal maximum.

The eligibility window is 30 days. For Medicaid for Adults, Children's Medicaid, and CHIP decisions about eligibility or the amount of your benefit, you have 30 days from the date on your notice to file an appeal.1

The service window is 28 days. For a Division of Medicaid service decision, such as developmental-disability services or a level-of-care determination, you have 28 days from the date on your notice to file.1

Both windows sit below the federal ceiling. Under 42 CFR 431.221(d), a state must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a hearing, and a state may set a shorter operational window.4 Idaho's 30-day and 28-day windows are those shorter windows, so do not assume you have 90 days. Read the deadline off the notice in front of you, because the Idaho window runs from the date printed on the notice.

One more rule protects renewals. If your coverage ended only because you did not return a renewal form or requested information on time, you may not have to 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 an Idaho Medicaid appeal

Continued benefits during an appeal are sometimes called aid paid pending, and in Idaho they are not automatic.

You must ask within 10 days. If you want your benefits to continue while your appeal is pending, you must tell DHW to continue them within 10 days of the date on your notice.1 This is Idaho's operational version of the federal continuation rule. Under 42 CFR 431.230(a), when the agency sends the required advance notice and you request a hearing before the action takes effect, it may not reduce or terminate your services until a decision is rendered after the hearing.6

Continued benefits are not free if your appeal fails. In Idaho, if the appeal is denied, you are responsible to repay the benefits you received during the appeal period.1 Federal law works the same way: 42 CFR 431.230(b) lets the agency recoup the cost of services that were furnished only because benefits were continued.6

When an adverse-action notice arrives, find its date, and if you want your coverage to hold, put your request to continue benefits in writing within 10 days. Continuation is a request, not a default.

Managed care appeals: exhaust the plan first

Idaho does not run risk-based managed care for all services. Most primary care runs through the Healthy Connections primary-care case-management program, but the state carves specific services out to risk-based managed-care plans, and those plan-delivered services follow the federal managed-care appeal rules first.1

Idaho's managed-care plans are the Idaho Behavioral Health Plan (Magellan), the Idaho Smiles dental plan (MCNA), and, for people who have both Medicare and Medicaid, the Medicare Medicaid Coordinated Plan and the Idaho Medicaid Plus plans (Molina Healthcare of Idaho and UnitedHealthcare Community Plan of Idaho).1 If one of these plans denies, reduces, suspends, or ends a service, you appeal to the plan before you can reach a state fair hearing.

The plan must notify you first. Under 42 CFR 438.404, a managed-care plan must give you timely written notice of an adverse benefit determination that explains the decision, your right to appeal, how to request an expedited appeal, and your right to ask that benefits continue during the appeal.7

You file the plan appeal within 60 days. You have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal, and a plan has only one level of appeal, which you must exhaust before requesting a state fair hearing.2

The plan then decides on a clock. A standard appeal must be resolved within 30 calendar days and an expedited appeal within 72 hours, though either can be extended by up to 14 calendar days when you request it or the plan shows the state that more information is needed and the delay is in your interest.8 Ask for the expedited track whenever waiting on the standard timeline could seriously jeopardize your health or ability to regain function.

Only then do you request the state fair hearing. After the plan upholds its denial, 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 set by the state.9

How to request an Idaho Medicaid fair hearing

Filing in the right place, the right way, keeps your appeal on the clock. In Idaho, you file the appeal with DHW, and the Idaho Office of Administrative Hearings (OAH) holds the hearing.

You have three ways to file. You can request an appeal by completing DHW's Fair Hearing Request form and mailing it, by requesting an appeal in writing by mail, email, or fax, or by calling to request one.1 DHW's Self-Reliance Programs receives appeals at the following contacts:

• Mail: Self-Reliance Programs, P.O. Box 83720, Boise, ID 83720-00261
• Email: mybenefits@dhw.idaho.gov1
• Fax: 866-434-8278 (toll free)1
• Phone: 877-456-1233 (toll free)1

An independent officer hears your case. The administrative hearing is conducted by the Idaho Office of Administrative Hearings, a separate state tribunal, before a third-party, independent hearing officer, and most hearings are held by telephone.1 The hearing officer reviews the decision you are appealing and issues a ruling; bring the documents that support your case, such as pay records for an income dispute or a letter from your treating provider for a medical-necessity or level-of-care dispute.

Learn More

Find personalized help navigating an Idaho 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.