Michigan Medicaid Appeals and Fair Hearings

If your Michigan 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 decided.1 One deadline decides whether that coverage keeps flowing: the effective date of the action printed on your notice, which comes before the longer window you have to file the appeal itself.2

In This Guide

• What You Can Appeal
• Michigan Medicaid Appeal Deadlines
• How to Keep Your Benefits During the Appeal
• Health Plan (Managed Care Organization) Appeals
• How to Request a Fair Hearing in Michigan
• Frequently Asked Questions

What you can appeal in Michigan 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 Medicaid statute (42 U.S.C. 1396a(a)(3)) requires the state plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted upon with reasonable promptness, and the implementing rule at 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.1

In Michigan, that right covers the full range of actions MDHHS or a contracted plan can take against you:

• An application denial (income, assets, household composition, or documentation)
• A termination or reduction of your eligibility
• A reduction in service hours, such as personal care or home-help hours
• A denial, reduction, suspension, or termination of a covered service by your health plan
• A prior-authorization denial or a level-of-care determination
• A denial at renewal or recertification

Michigan Medicaid appeal deadlines that decide your case

Two deadlines matter most in a Michigan Medicaid appeal, and they are not the same number.

The request window is 90 calendar days. Michigan applies the federal ceiling rather than a shorter state window. Under 42 CFR 431.221(d), the agency must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a hearing, and Michigan's Bridges Administrative Manual sets the client's window at 90 calendar days from the date of the written notice of case action, with the request required to be received within that time.3,4 Read the date off your own notice and count from there.

The keep-your-benefits window is earlier: before the effective date. Requesting the hearing inside the 90-day window preserves your right to a decision; requesting it before the action takes effect is what preserves the coverage itself.

If a health plan denied your care, two more windows apply: 60 calendar days to file the plan's internal appeal, then a further window to request a state fair hearing after the plan rules against you. Those are covered under health plan appeals below.

One separate deadline protects renewals. If Michigan terminated your coverage only because you did not return a renewal form on time, you do not always have to reapply: under 42 CFR 435.916, if you submit the renewal form within 90 days after the termination date, the agency must reconsider your eligibility without a new application. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Michigan may offer the same window but is not required to, so ask MDHHS.5

How to keep your benefits during the appeal

Keeping your benefits during an appeal is called aid paid pending. It is a distinct protection with its own deadline, and it is not automatic: you have to request the hearing in time to trigger it.

For Medicaid specifically, MDHHS must maintain your benefits if you request the hearing before the effective date of the adverse action. If a termination is set to take effect on January 1, the request has to be filed by December 31 to keep coverage running while the appeal is decided.3

That state rule tracks the federal continuation regulation. 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, your services continue until a hearing decision is rendered, unless the sole issue is one of federal or state law.2 The trigger is the effective date on the notice, not a flat count of days after you receive it.

There is one cost if you lose. If your benefits continue and the agency's action is later upheld at the hearing, 42 CFR 431.230(b) permits the agency to recover the cost of the services it furnished solely because benefits were continued.2 That recovery is the trade-off for keeping coverage during the appeal.

Health plan (managed care organization) appeals: exhaust the plan first

Michigan runs Medicaid largely through managed care under the Comprehensive Health Care Program, so most beneficiaries get care through a Medicaid Health Plan, also called a managed care organization (MCO). When your plan denies care, you appeal to the plan before you can reach a state fair hearing. A recipient enrolled in a Medicaid Health Plan, a Community Mental Health Services Program Pre-Paid Inpatient Health Plan (CMHSP-PIHP), or a MI Choice Waiver agency must exhaust that organization's internal appeal before becoming eligible to request a state fair hearing from MOAHR.3 Skipping the plan appeal and going straight to a hearing gets the request dismissed.

The nine health plans awarded Comprehensive Health Care Program contracts effective October 1, 2024, whose internal appeal you must exhaust first, are Aetna Better Health of Michigan, Blue Cross Complete of Michigan, HAP CareSource, McLaren Health Plan, Meridian Health Plan of Michigan, Molina Healthcare of Michigan, Priority Health Choice, and United Healthcare Community Plan, plus Upper Peninsula Health Plan for members in the Upper Peninsula.3

These plan-level rules come from the federal managed care regulations at 42 CFR Part 438:

• Plan denials. Under 42 CFR 438.404, the plan must give you timely, written notice of an adverse benefit determination, the decision you are appealing, and that notice must explain how to appeal and how to ask that your benefits continue.6
• Internal appeal window. You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, which you can request orally or in writing.7
• Decision timing. The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours. Either timeframe can be extended by up to 14 calendar days if you request it or the plan shows more information is needed and the delay is in your interest.8 Ask for the expedited 72-hour track when waiting for the standard timeline could put your health at serious risk.
• State fair hearing after the plan. Once the plan upholds its denial, 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.8

How to request a fair hearing in Michigan

Michigan Medicaid fair hearings are held by MOAHR, a Type 1 agency within the Department of Licensing and Regulatory Affairs; its Benefit Services Division adjudicates hearings for MDHHS Medicaid actions.3 An Administrative Law Judge (ALJ) takes the evidence and issues the decision.

You request a hearing by filing the written request form that matches your issue and mailing it to MOAHR. The form depends on what you are contesting:

• DCH-0018, Request for Hearing, to contest an MDHHS eligibility action, meaning a decision to deny, reduce, or terminate benefits.
• DCH-0092 for a Medicaid service-level issue.
• MDHHS-5617 (MAHS), Request for State Fair Hearing, for an action taken by a managed care organization after you have exhausted the plan's internal appeal.

The forms can be completed on a computer or by hand and mailed to MOAHR.3 For Medicaid beneficiaries, a toll-free help line is available at 1-800-648-3397.3 A client can file the request, or an authorized hearing representative can file on their behalf.

Learn More

Find personalized help navigating a Michigan 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.