Kentucky Medicaid Appeals and Fair Hearings Guide

If your Medicaid coverage in Kentucky was denied, cut, or terminated, you have the right to appeal, request a fair hearing, and often keep your benefits while the appeal is decided.1 The deadline that governs your case depends on which kind of Medicaid you have: a fee-for-service action runs on one clock, and a managed-care denial runs on another.1

In This Guide

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

What You Can Appeal in Kentucky 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 Kentucky'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 implementing regulation, 42 CFR 431.220, extends that right to anyone who believes the agency acted erroneously, denied a claim for eligibility or covered services, or issued a liability determination, and also to nursing-facility residents facing a transfer or discharge, people disputing a PASRR determination, and managed-care enrollees.2 The right has one stated limit: the agency need not grant a hearing when the sole issue is a federal or state law that automatically changes benefits for some or all beneficiaries.2

In Kentucky, an applicant or recipient who disagrees with an adverse action (a denial, reduction, discontinuance, or patient-liability determination) has the right to a state administrative fair hearing before the Kentucky Cabinet for Health and Family Services (CHFS).1 In practice, that means you can appeal:

• A denial of your application (income, assets, or documentation)
• A termination, reduction, or discontinuance of a covered service
• A prior-authorization decision
• A patient-liability determination (the share of nursing-facility cost you are expected to pay)
• A PASRR determination for nursing-facility placement
• A nursing facility's decision to transfer or discharge you2
• A managed-care plan's denial, reduction, or termination of a service, after you appeal the plan first

Kentucky Medicaid Appeal Deadlines That Decide Your Case

The deadline that applies depends on whether the action came from the state directly, as a fee-for-service Medicaid decision, or from your managed-care plan.

Fee-for-service: 30 calendar days

For a non-managed-care appeal of a discontinuance of services, a PASRR determination, or a patient-liability determination, Kentucky requires the written request be postmarked within 30 calendar days of the date on the department's written notice of adverse action.1 That state window is shorter than the federal maximum: 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 the 90 days is a ceiling a state may shorten, not a window you are entitled to.1 Read the deadline off your own notice, not off the federal ceiling: Kentucky's shorter 30-day window is the one that binds you, and it is fully enforceable.

The keep-your-benefits window: 10 days

A separate, earlier deadline decides whether your care continues while you appeal. It is covered in the next section.1

Managed care: 60 days to the plan, then 120 days to the state

If your denial came from a managed-care plan, Kentucky gives you 60 calendar days from the date you receive the plan's notice to file its internal appeal.1 Federal rules count the same 60 days from the date printed on the notice, so counting from that earlier date keeps you safe under both.3 After the plan upholds its decision, Kentucky gives you 120 calendar days from the date of the plan's final adverse-action letter to request a state fair hearing.1 Federal law sets that state window between 90 and 120 calendar days, and Kentucky uses the full 120.4

One more rule protects renewals. If your coverage ended only because you did not return a renewal form on time, you may not need to reapply: under 42 CFR 435.916, if you submit the renewal form within 90 days after the termination date (or a longer period the state chooses), the agency must reconsider your eligibility in a timely manner without a new application. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through SSI, age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, federal rules let Kentucky offer the same window but do not require it, so ask the Department for Medicaid Services.5

How to Keep Your Benefits During a Kentucky Medicaid Appeal

Keeping your benefits during an appeal is called "aid paid pending." It is not automatic, and it runs on a shorter clock than the deadline to appeal.

The Kentucky rule

If your written hearing request is postmarked or received within 10 days of the advance-notice date of the denial, you remain eligible for the care, program participation, or service until the date a final order is rendered.1 The protection has limits. It does not apply when the service was reduced or stopped because of a change in law or regulation, when your eligibility for time-limited benefits has expired, or when you have already received the full authorized amount of care, and it ends if the hearing finds the only issue is one of law or policy and DMS promptly tells you in writing that services will stop pending the decision.1 Miss that 10-day window and, even if your fuller 30-day or 120-day deadline to appeal is still open, your services can stop while the appeal is pending.

The federal foundation

Kentucky's 10-day rule operationalizes a federal protection. 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, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless both the hearing finds the sole issue is one of federal or state law or policy and the agency promptly tells you in writing that services will stop pending the decision.6 A request made after that date does not trigger continuation, though a separate rule lets the agency reinstate services if you request the hearing within 10 days of the action.6 If the agency cut you off without the required advance notice, it must reinstate your services when you request a hearing within 10 days of receiving the notice (counted as 5 days after its date unless you show it arrived later), as long as the action was not simply the application of federal or state law or policy.6 Continuation carries a risk: if the hearing upholds the agency's action, it may recover the cost of services you received only because of the continuation.6

When any adverse-action notice arrives, find the advance-notice date on it and get your written request in within 10 days.

Managed Care (MCO) Appeals: Your Plan First, Then the State

Kentucky Medicaid offers five managed-care organizations that members choose among: Aetna Better Health of Kentucky, Humana Healthy Horizons in Kentucky, Passport Health Plan by Molina Healthcare, UnitedHealthcare Community Plan, and WellCare of Kentucky.1 If you are enrolled in one of these plans and it denies care, you appeal to the plan before you can reach a state fair hearing.

What counts as a plan denial

Under 42 CFR 438.404, your plan must give you timely, adequate written notice of an adverse benefit determination, such as a denied service authorization, a termination, suspension, or reduction of a service already authorized, a denial of payment, or a decision not reached in time. That notice must tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue during the appeal.7

The internal appeal and exhaustion

Each plan may have only one level of appeal, and you can request it orally or in writing.3 In Kentucky, you have 60 calendar days from the date you receive the plan's notice to file, and an oral appeal must be followed within 10 calendar days by a written appeal signed by you or by a legal guardian or authorized representative. You must exhaust this appeal before the state will hold a fair hearing.1

How fast the plan must decide

The plan must decide as quickly as your health condition requires, within limits the state sets under federal caps: no more than 30 calendar days from when the plan receives a standard appeal, and no more than 72 hours for an expedited one.4 Either deadline can be extended by up to 14 calendar days, if you ask for the extension or if the plan shows the state it needs additional information and how the delay is in your interest. If the plan extends without your request, it must tell you in writing within 2 calendar days why, and that you can file a grievance if you disagree.4 If waiting could harm your health, ask for an expedited appeal; the plan's denial notice must explain when an appeal can be expedited and how to request it.7

After the plan upholds its denial

Once the plan issues its final adverse-action letter, you have 120 calendar days to request a state fair hearing with the Department for Medicaid Services.1 To keep receiving the service while the hearing is pending, though, federal rules require you to request both the hearing and continued benefits within 10 calendar days after the plan sends its appeal decision; wait longer and you keep the hearing but lose the coverage in the meantime.4 If the plan fails to follow the federal notice and timing requirements for deciding appeals (42 CFR 438.408), you are deemed to have exhausted its appeal process and may request the state hearing without waiting.4

How to Request a Kentucky Medicaid Fair Hearing

Whichever track you are on, the state hearing itself runs through the Cabinet for Health and Family Services, and the request goes to the same place: the Department for Medicaid Services (DMS).

Learn More

Find personalized help navigating a Kentucky 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.