Indiana Medicaid Appeals and Fair Hearings: How to Appeal

If your Indiana Medicaid 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 pending.1 Indiana calls the decision you are challenging an "action," and it requires you to file your appeal in writing within 33 days of the notice.2

In This Guide

• What You Can Appeal in Indiana Medicaid
• Indiana Medicaid Appeal Deadlines That Decide Your Case
• How to Keep Your Benefits During the Appeal
• Managed Care (MCO) Appeals: Appeal Your Plan First
• How to Request an Indiana Medicaid Fair Hearing
• Frequently Asked Questions

What You Can Appeal in Indiana 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 Indiana'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, denied a claim for eligibility or covered services, or made an adverse determination.1

In Indiana, the decision you are challenging is called an "action," and an appeal is a request for a fair hearing before an administrative law judge (ALJ).2 In practice, you can appeal:

• An application denial for Medicaid eligibility
• A termination or reduction of eligibility or covered services
• A cut in the hours or amount of an already-authorized service
• A prior-authorization denial or a denial of covered health care

The right reaches across the program, whether the decision came from the state or from your managed-care health plan.1

Indiana Medicaid Appeal Deadlines That Decide Your Case

Indiana Medicaid appeals run on more than one clock, and the deadline depends on which step you are at.

The request window in Indiana is 33 days. Indiana requires you to file your appeal in writing by close of business within 33 days of the date of the notice or the adverse action, whichever is later.2 Federal law sets only a ceiling here: under 42 CFR 431.221(d), a state must allow a reasonable time, not to exceed 90 days from the date the notice is mailed, to request a hearing, and Indiana's 33-day window is the shorter operational deadline the federal rule permits.3 Read the date off your own notice and do not assume 90 days.

To keep your benefits flowing during the appeal, you have to file earlier than the 33-day deadline, before the effective date of the change stated in your notice. That window is covered in the next section.2

The managed-care deadlines are different again. If your denial came from a managed-care plan, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.5 After the plan resolves that 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 set by the state.6

One more deadline protects 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 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.7

How to Keep Your Benefits During the Appeal

Keeping your benefits during the appeal is called "aid paid pending," and it is not automatic. The trigger is the effective date on your notice, not a flat count of days.

The Indiana rule. If you submit your appeal request before the effective date of the change in your coverage listed in the notice, you keep the same level of benefits you are receiving now while the appeal is pending.2 This carries out the federal rule at 42 CFR 431.230(a): when the agency sent 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.4

Members of HIP Plus or HIP State Plan Plus must keep making the required monthly POWER (Personal Wellness and Responsibility) account contribution during the appeal to continue receiving those benefits.2

A request made after the action has already taken effect does not trigger continuation. A different provision, 42 CFR 431.231, lets the agency reinstate services when you request a hearing not more than 10 days after the date of action.4 This 10-day figure is reinstatement, not continuation, so do not treat it as your real deadline.

If your benefits continue and the agency's action is later upheld at the hearing, 42 CFR 431.230(b) permits the agency to recoup the cost of the services provided solely because benefits were continued.4

Managed Care (MCO) Appeals: Appeal Your Plan First

Many Indiana Medicaid members get their care through a managed-care organization (MCO), a private health plan the state pays to run their benefits. If your denial came from an MCO, you appeal to the plan before you can reach a state fair hearing.2 Indiana runs several managed-care programs, each with its own set of plans.

If you are enrolled in the Healthy Indiana Plan, Hoosier Healthwise, or Hoosier Care Connect, contact your plan and work through its appeal process first.2 These steps come from the federal managed-care rules at 42 CFR Part 438.

The plan's notice. 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 an already-authorized service, or a denial of payment. That notice has to tell you how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue during the appeal.8

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 complete it before requesting a state fair hearing.

The plan's deadline to decide. The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours of receiving it, and 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.9 Ask for the expedited track when waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

If the plan fails to meet the notice and timing rules, the appeal is deemed exhausted and you may go straight to a state fair hearing.8 Once the plan upholds its decision, you then have 90 to 120 days, set by the state, to request that hearing.6

How to Request an Indiana Medicaid Fair Hearing

In Indiana, an appeal is a request for a fair hearing before an administrative law judge (ALJ) at the Office of Administrative Law Proceedings (OALP), the office that in 2024 took over the hearings formerly heard by the Family and Social Services Administration (FSSA) Office of Hearings and Appeals.2 Every appeal must be made in writing, and there is no fee.2

How you file depends on what the action was:

• For an eligibility action (income, assets, or your ongoing eligibility), follow the process described in the written notice you received from the Family and Social Services Administration and its Division of Family Resources (DFR).2
• For a health care or covered-services action, a member in the Healthy Indiana Plan, Hoosier Healthwise, or Hoosier Care Connect must first work through the health plan's appeal process. A member in any other Indiana Health Coverage Program can write a letter, stating the member's name, the reason for the appeal, and the dates of the action, to the Office of Administrative Law Proceedings, FSSA Hearings.2

The OALP can be reached at 402 W. Washington St., Rm E034, Indianapolis, IN 46204; by fax at 317-232-4412; by email at fssa.appeals@oalp.in.gov; or by phone at 317-234-3488 or 1-866-259-3573.2

Learn More

Find personalized help navigating an Indiana 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.