Medicaid Aid Paid Pending: Keep Coverage During an Appeal

If your Medicaid notice says your coverage is ending or being cut, you may be able to keep it in place while you appeal. That protection is called aid paid pending, and one deadline decides whether you get it. Under 42 CFR 431.230(a), when the agency sends the required advance notice and you request a fair hearing before the action takes effect, the agency may not terminate or reduce your services until a decision is issued after the hearing.1 Request the hearing after that date and the rule works differently.

In This Guide

• Key Takeaways
• What Medicaid Aid Paid Pending Means
• The Deadline That Decides Whether Benefits Continue
• How Medicaid Aid Paid Pending Works, Step by Step
• The Trade-Off: You May Have to Pay It Back
• Requesting a Hearing vs. Keeping Your Benefits
• What to Do Right Now
• Frequently Asked Questions
• Learn More

What Medicaid Aid Paid Pending Means

Every Medicaid applicant and beneficiary has the right to a fair hearing before the state agency when the agency denies a claim, ends coverage, or makes another adverse decision. That right comes from section 1902(a)(3) of the Social Security Act and its implementing rule, 42 CFR 431.220.3

Aid paid pending is a separate protection that sits on top of that right. It answers a narrower question: while your appeal is being decided, does your coverage keep running or does it stop on the date the notice says? Under 42 CFR 431.230(a), if the agency sent you the required 10-day (or 5-day) advance notice and you request a hearing before the date of action, the agency may not terminate or reduce your services until a decision is rendered after the hearing.1 In plain terms: the coverage, service level, or benefit you have today stays exactly as it is while you wait.

There is one carve-out written into the rule itself. If the only issue in dispute is a matter of federal or state law or policy, rather than the facts of your own case, the agency is not required to keep your services running during the appeal.1

The Deadline That Decides Whether Benefits Continue

The whole protection turns on timing, so it helps to separate the two dates on your notice.

Before a state can end or reduce ongoing benefits, it must mail you an advance notice, at least 10 days (in some situations 5 days) before the action takes effect. The date of action is that effective date, the day the change is scheduled to happen. Aid paid pending is keyed to that date: you must request the hearing before it arrives.1

That is why the practical window many families see is short, often the 10 days between the notice and the effective date. The exact request window and how your state counts it are set at the state level, so confirm the deadline on your own notice rather than assuming a fixed number of days. Our Medicaid by State directory links to each state's agency and appeals process.

Two things to keep straight:

• Request the hearing before the date of action, and your benefits continue at their current level until the decision.1
• Request it after that date, and continuation under 431.230 no longer applies. A related rule, 42 CFR 431.231, lets the agency reinstate your services if you request a hearing not more than 10 days after the date of action, so acting fast still matters even if the effective date has passed.1

How Medicaid Aid Paid Pending Works, Step by Step

The Trade-Off: You May Have to Pay It Back

Continuation is not free of risk, and this is the part to weigh before you ask for it.

If the hearing officer ultimately sustains the agency's action, meaning you lose the appeal, 42 CFR 431.230(b) allows the agency to recoup the cost of the services it furnished solely because your benefits were continued.1 In other words, the coverage you kept during the appeal was provisional. Win, and the interruption never happens. Lose, and you can be asked to repay the value of what you received while the case was open.

How to think about it:

• If you have a strong factual dispute, for example the agency terminated you over paperwork that was actually returned, continuation protects care you are likely entitled to keep.
• If your appeal is a long shot, continuing benefits you will probably have to repay can leave you worse off than accepting the change and pursuing the appeal without continuation.

There is no single right answer. The point is to make the choice deliberately, knowing that continuation can be clawed back if the decision goes against you.

Requesting a Hearing vs. Keeping Your Benefits

These are two different deadlines, and confusing them can cost you coverage you could have kept. One protects your right to be heard; the other protects your benefits in the meantime.

Under 42 CFR 431.221(d), your state must give you a reasonable time, not more than 90 days from the date the notice is mailed, to request a hearing.2 Some states set a shorter operational window for certain decisions, so read your notice.2

The trap is that the 90-day figure is easy to fixate on. You can file well within 90 days, get your hearing, and still watch your coverage stop, because you filed after the date of action rather than before it. If keeping your benefits during the appeal matters to you, the earlier, benefit-continuation deadline is the one that governs. For the full appeal process, see our guide to appealing a Medicaid denial.

What to Do Right Now

1. Find the date of action on your notice. That effective date is your deadline to keep benefits. Mark it.1

2. Request the fair hearing before that date. Follow the appeal instructions on the notice, and file before the action takes effect.1

3. Ask, in writing, for your benefits to continue. Filing the appeal may not be enough on its own. State that you want continuation while the case is pending, and keep proof of when you sent it.

4. Confirm the details with your state agency. The exact window, how continuation is requested, and how recoupment is handled all vary by state. Start with your state's page in the Medicaid by State directory.

5. If the effective date has already passed, ask about reinstatement under 431.231 if you are within 10 days of the date of action, and file your hearing request anyway to preserve your appeal.1

Learn More

Find personalized help keeping your Medicaid coverage in place during an 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.