Iowa Medicaid Appeals and Fair Hearings: How to Appeal

If your Iowa Medicaid coverage or a covered service was denied, reduced, or terminated, you have the right to appeal and request a fair hearing before the state.1,2 In Iowa you have 90 calendar days from the date on your written notice to request that hearing for an eligibility or fee-for-service action, and 120 calendar days for a managed care or dental-carrier action.2 If you file before the action takes effect, you can often keep your benefits while the appeal is decided.3

In This Guide

• What You Can Appeal in Iowa Medicaid
• Iowa Medicaid Appeal Deadlines That Decide Your Case
• How to Keep Your Benefits During an Iowa Medicaid Appeal
• Managed Care (MCO) Appeals: Exhaust Your Health Plan First
• How to Request an Iowa Medicaid Fair Hearing

What You Can Appeal in Iowa Medicaid

Federal Medicaid law gives 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 Iowa's Medicaid plan to grant a hearing to anyone whose claim for assistance is denied or is not acted on promptly, and 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.1

In Iowa, that means you can appeal:

• A denial of your Medicaid application, whether the reason was income, assets, or documentation
• A termination or reduction of your eligibility or a covered service
• A cut to authorized service hours, such as home care or attendant care under a Home and Community-Based Services (HCBS) waiver
• A prior-authorization denial or a level-of-care decision
• A managed care plan's denial, reduction, suspension, or termination of a service5

The right reaches across the program, from the application desk to a service already in place.1

Iowa Medicaid Appeal Deadlines That Decide Your Case

Iowa sets two request windows for a fair hearing: 90 calendar days for a Medicaid eligibility or fee-for-service action, and 120 calendar days for a managed care or dental-carrier action.

For a Medicaid eligibility decision or a fee-for-service action, you have 90 calendar days from the date on the written notice to request a fair hearing.2 That 90 days is also the federal ceiling under 42 CFR 431.221(d): no state can require a request in fewer than 90 days.4

If your denial came from a managed care organization (MCO) or a dental carrier, Iowa gives you 120 calendar days to appeal.2 That sits at the top of the federal band: once your health plan upholds its denial, 42 CFR 438.408(f) requires the state to allow no fewer than 90 and no more than 120 calendar days from the plan's notice of resolution to request a state fair hearing.6

Read the deadline off your own notice, and count from the date the notice was mailed, not the day it reached your mailbox.

One more deadline protects renewals. If Iowa ended your coverage 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 an Iowa Medicaid Appeal

Keeping your benefits while the appeal is pending is called aid paid pending. It is not automatic: you have to file in time and ask for it.

Under 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, it may not reduce or end your services until a decision is issued after the hearing.3 The trigger is the effective date on your notice, not a flat count of days.

For a managed care service that is being reduced, suspended, or canceled, Iowa continues the service while the appeal is pending if you file on or before the effective date of the plan's adverse benefit determination, or within 10 calendar days of the date you received the plan's notice.2

Benefits paid while your appeal is pending can be recovered. If the Iowa Department of Health and Human Services is later found to have acted correctly, you may have to repay the cost of the assistance you were not entitled to.2 Federal law permits that recoupment under 42 CFR 431.230(b).3

When any adverse-action notice arrives, find the effective date, file before it, and put your request to continue benefits in writing.

Managed Care (MCO) Appeals: Exhaust Your Health Plan First

Most Iowa Medicaid members get their care through Iowa Health Link, the state's managed care program, and choose one of three managed care organizations (MCOs): Iowa Total Care, Molina Healthcare, or Wellpoint (formerly Amerigroup Iowa).2 When your plan denies care, you appeal to the plan before you can reach a state fair hearing. These rules come from the federal managed care regulations at 42 CFR Part 438.

Under 42 CFR 438.404, your plan must give you timely written notice of an adverse benefit determination, including a reduction, suspension, or termination of a service it already approved. That notice must tell you how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue.5

You have 60 calendar days from the date on the plan's determination notice to file the plan's internal appeal, which you can request orally or in writing.8 The plan has only one level of appeal, and you must complete it before you request a state fair hearing. A fair-hearing request filed before the plan's first-level review is finished is denied as premature and sent back to the plan.2

The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours. Either deadline 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 whenever waiting on the standard timeline could seriously jeopardize your health.

Once the plan issues its notice of decision, you can request a state fair hearing, and Iowa gives you 120 calendar days from that notice to do it.2,6

How to Request an Iowa Medicaid Fair Hearing

In Iowa, you request a fair hearing through Iowa HHS Appeals, the appeals unit of the Iowa Department of Health and Human Services. A Medicaid appeal can be made in person, by telephone, or in writing, and there is no fee to file.2 You can write a letter explaining why you disagree, complete the online Appeal and Request for Hearing form, or fill out that form at a local Iowa HHS office.2

File your request with Iowa HHS Appeals:

• Mail: Iowa Department of Health and Human Services, Appeals, 321 E 12th Street, Des Moines, IA 50319
• Phone: 1-888-723-96372
• Fax: 515-564-4044
• Email: appeals@hhs.iowa.gov

Once your hearing is granted, Iowa HHS Appeals forwards your file to the Administrative Hearings Division of the Iowa Department of Inspections, Appeals, and Licensing (DIAL), which schedules a telephone hearing before an administrative law judge (ALJ) and mails you written notice of the date and time.2

Learn More

Find personalized help navigating an Iowa 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.