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 date or the action date, whichever is later.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 gives Medicaid applicants and beneficiaries a 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 offer a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness. The regulation that carries it out, 42 CFR 431.220, extends the right to anyone who believes the agency acted erroneously, denied a claim for eligibility or covered services, decided what they owe, or did not act on their claim promptly. That includes a spend-down determination, premiums and cost sharing, a change in the amount or type of services, and a prior authorization decision. It also covers nursing facility residents facing a transfer or discharge they believe is wrong, and managed-care enrollees entitled to a hearing under the federal managed-care rules. The one stated exception: the agency need not grant a hearing when the only issue is a federal or state law that requires an automatic change affecting some or all beneficiaries.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 applies whether the decision came from the state or from your managed-care health plan, though a plan decision usually goes through the plan's own appeal first (see below).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 Indiana counts that deadline strictly. "Close of business" means 4:30 PM local time where the appeal is received, and a deadline that falls on a weekend or holiday moves to the next business day. A mailed appeal counts as received on the day FSSA gets it, not the postmark date, so a letter postmarked on day 33 is late.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.2 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.4 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.5

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 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 SSI, 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 FSSA whether Indiana does.6

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. The only exception needs two things together: the hearing finds that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that your services will be cut pending the decision.3

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. The appeal does not pause that requirement, and stopping payment can cost you those benefits and possibly your HIP eligibility. Even if the judge rules in your favor and your coverage is restored, you will owe any POWER payments you missed during the appeal, and FSSA says you will lose HIP eligibility or HIP Plus benefits if that full amount is not repaid on time.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. If the agency cut you off without sending the required advance notice at all, reinstatement is not optional: it must restore your services until the hearing decision if you request a hearing within 10 days of receiving the notice (counted as 5 days after the date on it unless you show it arrived later) and the action did not result from applying federal or state law or policy.3 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.3

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 ordinarily appeal to the plan before you can reach a state fair hearing.5 Indiana runs several managed-care programs, each with its own set of plans.2

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. FSSA's member appeals page names only those three programs for this plan-first step and says nothing either way about PathWays for Aging, so a PathWays member should follow the instructions on the notice they received.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 and adequate notice in writing of an adverse benefit determination, such as a service-authorization denial, a termination, suspension, or reduction of an already-authorized service, or a denial of payment. That notice has to explain the decision and the reasons for it, your right to free copies of the documents behind it (including the medical-necessity criteria), how to appeal and request a state fair hearing, when an appeal can be expedited and how to ask for that, and how to request that your benefits continue during the appeal.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.4 The plan may have only one level of appeal, and you ordinarily complete it before requesting a state fair hearing.4

The plan's deadline to decide. The plan must decide your appeal as quickly as your health condition requires, within a state deadline that federal rules cap at 30 calendar days for a standard appeal and 72 hours for an expedited one, counted from when the plan receives it. Those are ceilings, not a period the plan is entitled to use. Either deadline can be extended by up to 14 calendar days if you ask, or if the plan shows the state that it needs more information and how the delay is in your interest. If the plan extends without your asking, it must make reasonable efforts to tell you promptly, give you the reason in writing within 2 calendar days, and tell you that you can file a grievance if you disagree.5 Your plan's notice must explain when an appeal can be expedited and how to ask for it, so check it if waiting weeks could harm your health.7

If the plan fails to follow 42 CFR 438.408's notice and timing requirements for resolving your appeal, you are treated as having finished the plan's appeal process and may go straight to a state fair hearing.5 That turns on how the plan handles your appeal, so file the plan's internal appeal within 60 calendar days of the date on the determination notice either way.4 Once the plan upholds its decision, you then have 90 to 120 days, set by the state, to request that hearing.5

Keeping your plan services during the appeal. Benefits do not continue automatically, and the clock is far shorter than the filing deadline. To keep a previously authorized service going during the plan appeal, you must file the plan appeal on time and ask for continued benefits by the later of 10 calendar days after the plan sends its notice of the decision or the date the change is set to take effect, and the service must have been ordered by an authorized provider within an authorization period that has not expired. After the plan upholds its decision, continued benefits end unless you request the state fair hearing and continuation within 10 calendar days after the plan sends that notice. If you take the full 90 to 120 days to file, you keep the right to a hearing but lose the coverage in the meantime. And if the final decision goes against you, the plan may recover the cost of services you received only because benefits continued.5

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 now hears the matters previously decided 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). Those instructions have you send a signed letter with your name, case number, and reason, plus a copy of the entire notice, by mail to the FSSA Document Center, PO Box 1810, Marion, IN 46952, by fax to 1-800-403-0864, or by hand to your local DFR office.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. OALP notes that these contact details did not change when the hearings moved over, so use the contact information on the action you are disputing.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.