Minnesota Medicaid Appeals and Fair Hearings

If your Minnesota Medicaid coverage 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.1,2 Minnesota delivers most Medical Assistance and MinnesotaCare through managed care health plans, so the path usually starts with an appeal to your plan and, if that fails, a state fair hearing before the Department of Human Services.3

In This Guide

• What you can appeal in Minnesota Medicaid
• The Minnesota Medicaid appeal deadlines that decide your case
• How to keep your benefits during the appeal
• Managed care appeals: exhaust your health plan first
• How to request a fair hearing in Minnesota
• Frequently Asked Questions

What you can appeal in Minnesota 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 each state 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 at 42 CFR 431.220 extends it to anyone who believes the agency acted erroneously, denied a claim for eligibility or for covered services, or failed to act promptly, and also to managed care enrollees and to nursing facility residents told they must be transferred or discharged.1 The right has one stated limit: the agency doesn't have to grant a hearing when the only issue is a federal or state law that automatically changes benefits for some or all beneficiaries.1

In Minnesota, Medical Assistance (MA, the state's Medicaid program) and MinnesotaCare appeals cover the full range of actions that affect your coverage. If a service has been denied, reduced, or terminated, you can file an appeal and request a state fair hearing.3,1 That includes:

• A denial of your application for MA or MinnesotaCare
• A termination or reduction of eligibility or a covered service, including a cut to the hours of personal care you receive
• A denial of a service, such as a prior authorization denial1
• A renewal or recertification denial
• A health plan's denial, reduction, suspension, or termination of a service6
• A nursing facility's decision that you must be transferred or discharged1

The Minnesota Medicaid appeal deadlines that decide your case

Which deadline applies depends on who made the decision. A county or state decision has one clock; a health plan decision has several that run at once, each measured from a different event.3 The shortest is the 10-day window to keep your benefits during a health plan appeal.

Two points about these numbers. First, for a county or state decision, federal law sets an outer ceiling, not a guarantee: a state must allow a reasonable time, not to exceed 90 days from the date a notice of action is mailed, to request a hearing.7 Ninety days is the most a state may give you, not a minimum you are owed, and a shorter state deadline binds. DHS says you must usually ask within 30 days and some appeals may allow more time, so treat 30 days as your deadline unless the Appeals Division tells you otherwise.3 Health plan decisions follow a separate federal managed care rule that gives you 90 to 120 days to request a state fair hearing after the plan decides, and Minnesota uses 120.5 Either way, read the deadline off your own notice and don't assume you have longer.

Second, the deadlines for keeping your benefits are far shorter than the deadlines for filing the appeal itself. You have 60 days to file a health plan appeal, but only 10 days to file it in a way that keeps the disputed service flowing.3 Missing the 10-day window does not end your right to appeal; it ends your ability to keep the service while you do.

How to keep your benefits during the appeal

Keeping your benefits during an appeal is called aid paid pending. Don't assume it happens automatically; ask for it when you file. The window to secure it is short: 10 days from the date on the notice.2,3

The federal rule sits behind it. Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the action takes effect, the agency may not terminate or reduce your services until a decision is rendered after the hearing. That protection gives way only if 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.2 A request made after the action's effective date does not trigger that continuation, but it is not a dead end: a separate federal rule, 42 CFR 431.231, lets the agency reinstate services when you request a hearing no more than 10 days after the date of action. And if your services were cut without the advance notice the rules require, the agency must reinstate them when you request a hearing within 10 days of receiving the notice, unless the action came from applying federal or state law or policy.2

When a health plan made the decision, the federal managed care rule at 42 CFR 438.420 governs instead, and Minnesota applies it through two 10-day windows.3 To keep getting the disputed service while your health plan considers your appeal, file the plan appeal within 10 days of the date on the plan's notice. To keep the service flowing while your state appeal is considered, file the state appeal within 10 days of the date of the plan's appeal decision.3 Filing fast isn't enough on its own, though. The plan has to continue benefits only when the appeal involves ending, suspending, or reducing a service that was already authorized, an authorized provider ordered it, and the original authorization period hasn't run out. So if a plan denies a new service, that service won't be provided while you appeal.3

One caution before you rely on it. If your benefits continue during the appeal and the plan's or agency's action is later upheld, the plan or agency may recover the cost of the services that were furnished solely because your benefits continued.2,3 That is the tradeoff: continuing benefits protects your care during the fight, but a loss can carry a repayment.

Managed care appeals: exhaust your health plan first

Minnesota delivers most Medical Assistance and MinnesotaCare through managed care organizations (MCOs), the health plans that administer your benefits. When a health plan denies or cuts a service, you appeal to the plan first, and you must complete that internal appeal before you can request a state fair hearing.3 These rules come from the federal managed care regulations at 42 CFR Part 438.

DHS lists these managed care health plans on its health plan member services page: Blue Plus, HealthPartners, Hennepin Health, Itasca Medical Care, Medica, Medica One Health Plan, PrimeWest Health, and South Country.3 Your notice will name the plan that acted and tell you how to appeal to it.

What the plan's notice must tell you

Under 42 CFR 438.404, a managed care plan must give you timely, written notice of an adverse benefit determination, such as a service authorization denial, a reduction, suspension, or termination of a previously authorized service, or a denial of payment. That notice must explain the reasons for the action, your right to free copies of the records behind it (including the medical-necessity criteria the plan used), how to file the plan's one level of appeal, how to request an expedited appeal, how to reach a state fair hearing afterward, and how to ask for your benefits to continue during the appeal.6

The internal appeal and how fast the plan decides

You have 60 days from the date on the plan's notice to file the internal appeal.3,4 Filing is as simple as calling the plan; the phone number is on your notice and on the back of your health plan ID card. The plan gives you a written decision within 30 days. If you need a service urgently, ask for a fast appeal: if the plan agrees it's urgent, you get a decision within 72 hours, and if the plan disagrees, you can file a grievance.3 Under the federal rule, the standard and expedited timeframes can each be extended by up to 14 calendar days if you request the extension, or if the plan shows the state agency that it needs more information and how the delay is in your interest. If the plan extends without your asking, it must tell you in writing within 2 calendar days why, and you can file a grievance if you disagree.5

Then the state fair hearing

After the health plan issues its appeal decision, you request a state appeal in writing within 120 days of that decision.3 Federal law backs this up: once a plan upholds its determination, the state must give you no less than 90 and no more than 120 calendar days from the plan's notice of resolution to request a state fair hearing, and Minnesota sets that window at 120 days.5 There is one way around the plan appeal: if the plan fails to follow the federal notice and timing rules for deciding your appeal, you are treated as having finished the plan's process and can go straight to a state fair hearing.5

How to request a fair hearing in Minnesota

The Minnesota Department of Human Services (DHS) decides state appeals through its Appeals Division. The Appeals Division conducts administrative fair hearings for the department's health care programs, including MA and MinnesotaCare.3

To request a state fair hearing, complete the Appeal to State Agency form (DHS-0033). You can submit it online, or print it and mail it to Minnesota Department of Human Services, Appeals Division, PO Box 64941, St. Paul, MN 55164-0941, or fax it to 651-431-7523. You can also make a health plan appeal verbally by calling the Appeals Division at 651-431-3600.3 Whichever method you use, get the written request in by the deadline that applies to you (120 days after a health plan appeal decision, usually 30 days after a county or state decision) and, if you want your benefits to continue after a plan decision, file within the 10-day window and ask for continued benefits.3

You don't have to prepare alone. If you're in a health plan, DHS says the Ombudsperson for Public Managed Health Care Programs can help you request a state appeal and advise you on how to prepare for your hearing. It also notes that health plans overturn many decisions on appeal, so the plan appeal is worth pursuing.3 Bring the plan's or agency's notice, any letters from your treating provider documenting medical need, and any records that show you met the program's rules. For a service reduction or a level-of-care dispute, a letter from your physician documenting the need speaks directly to the question the hearing decides.

Learn More

Find personalized help navigating a Minnesota 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.