Missouri Medicaid Appeals and Fair Hearings

If your Missouri Medicaid was denied, reduced, or terminated, you have the right to appeal and request a state fair hearing, and you can often keep your benefits while the case is decided.1,2 In Missouri, MO HealthNet appeals are decided by the Benefit Hearings Unit of the Division of Legal Services, and the deadline that decides whether your benefits keep flowing is 10 days from the date on your notice, not the 90 days you have to file.2

In This Guide

• What You Can Appeal in Missouri Medicaid
• The Deadlines That Decide Your Missouri Medicaid Appeal
• How to Keep Your Benefits During a Missouri Medicaid Appeal
• Managed Care (MCO) Appeals: Exhaust Your Plan First
• How to Request a Missouri Medicaid Fair Hearing
• Frequently Asked Questions
• Learn More

What you can appeal in Missouri 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 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, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously, denied a claim for eligibility or services, or set their liability wrongly, as well as to nursing facility residents facing a transfer or discharge and to managed care enrollees. The right has one stated limit: the agency need not grant a hearing when the sole issue is a federal or state law requiring an automatic change that affects some or all beneficiaries.1

In Missouri, a participant or applicant who disagrees with a decision of the Department of Social Services (DSS), including the Family Support Division, the Children's Division, and the MO HealthNet Division, may appeal that decision and request a state fair hearing.2 In practice, that means you can appeal:

• An application denial for MO HealthNet (income, assets, household, or documentation)
• A termination or reduction of eligibility or of a covered service
• A reduction in authorized service hours, such as personal care or in-home services
• A prior-authorization decision, or the spend-down amount you must incur to qualify
• A nursing facility's decision to transfer or discharge you
• A managed care health plan's denial, reduction, suspension, or termination of a service1

If you already have coverage, federal rules generally keep your benefits in place while the appeal is pending when you request the hearing before the action takes effect. There is a narrow exception, and Missouri sets its own 10-day request deadline, both covered below.2

The deadlines that decide your Missouri Medicaid appeal

Missouri sets two filing windows for a state fair hearing: 90 days for fee-for-service MO HealthNet, and 120 days after a plan appeal for managed care.2 Which one applies depends on whether your MO HealthNet care is fee-for-service or through a managed care health plan.

For fee-for-service MO HealthNet, when a request for services is denied, reduced, or terminated, you have the right to a state fair hearing, and Missouri allows 90 days to request one.2 Ninety days is the ceiling federal law puts on that window, not a floor you are guaranteed: a state must allow a reasonable time that does not exceed 90 days from the mailing of the notice, and a state that sets a shorter deadline can enforce it.3 Missouri gives the full 90 days for fee-for-service decisions, but count carefully: the Family Support Division's hearings sheet runs the 90 days from the date shown on your Action Notice, while the federal rule runs them from the date the notice was mailed, so if those dates differ, count from whichever is earlier.2 If you do not receive a letter granting you 90 days, contact the MO HealthNet Participant Services Unit at 1-800-392-2161 and ask them to review the denial; if the denial is upheld, you will then be given 90 days to request a state fair hearing.2

If your denial came from a MO HealthNet Managed Care health plan, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.5 After the plan resolves that appeal against you, Missouri gives you 120 days from the date of the plan's Notice of Appeal resolution letter to request a state fair hearing.2,4

One more deadline protects renewals. If your MO HealthNet coverage was ended 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, Missouri may offer the same window but is not required to, so ask the Family Support Division.6

How to keep your benefits during a Missouri Medicaid appeal

The deadline to keep your benefits is much shorter than the deadline to appeal. The Family Support Division's hearings sheet says that if you want your benefits to continue while your hearing is pending, you must request the hearing within 10 days from the date shown on the Action Notice you got in the mail. So if you file after those 10 days but still within the 90, your appeal goes ahead, but your benefits do not continue while it is pending.2

Two federal rules can still help if you miss that window. If you are a few days late, ask anyway: 42 CFR 431.231(a) 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 required, 42 CFR 431.231(c) says the agency must reinstate them and keep them in place until the hearing decision when you request a hearing within 10 days of receiving the notice (counted as 5 days after the date on it unless you show it arrived later) and the agency determines the action turned on something other than applying federal or state law or policy.2 Not every cut-off without advance notice qualifies. Under 42 CFR 431.213 the agency may send notice as late as the date of action in some cases, such as when you were admitted to an institution where you are ineligible for further services or your physician prescribed a change in your level of care, and the regulations do not settle whether those cases count, so don't rely on mandatory reinstatement there. In those cases the first route still applies: request a hearing within 10 days after the date of action, and the agency may reinstate your services.2

The underlying federal rule, 42 CFR 431.230(a), protects you this way: if the agency sent the required advance notice and you request the hearing before the date of action on that notice, the agency may not terminate or reduce your services until a decision is rendered after the hearing. That has one exception, and both of its halves must be met: it is determined at the hearing that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that services are to be terminated or reduced pending the decision.2

Continuation is not automatic, so ask for it explicitly. When an Action Notice arrives, note the date shown on it, file your hearing request within 10 days of that date, and say in the request that you want your benefits to continue during the appeal.2

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 recoup the cost of the services furnished solely because benefits were continued.2 Weigh that risk before you ask for continuation.

Managed care (MCO) appeals: exhaust your plan first

If you are in MO HealthNet Managed Care, your care comes through a health plan, also called a managed care organization (MCO). Missouri's MO HealthNet Managed Care health plans are Healthy Blue, UnitedHealthcare, Home State Health, and Show Me Healthy Kids, the specialty plan for foster-care and former-foster youth.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, Subpart F.

Under 42 CFR 438.404, the plan must give you timely written notice of an adverse benefit determination, such as a denied service authorization, a reduction, suspension, or termination of a service already authorized, a denied payment, or a decision the plan did not make in time. The notice must explain the decision and your right to free copies of the records behind it, how to appeal, when and how you can get an expedited appeal, and how to ask that your benefits continue during the appeal.7

You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, and you can request it orally or in writing.5 To find the number to call, use the member-services line on the back of your MO HealthNet Managed Care health plan ID card.2 The plan has only one level of appeal, and you normally must complete it before requesting a state fair hearing. If the plan fails to meet its federal notice and timing requirements, though, you are deemed to have exhausted its appeal and can request the fair hearing without waiting.5,4 With your written consent, and if state law permits, a provider or authorized representative can file the appeal or request the hearing for you. If you are in an integrated plan that combines your Medicare and Medicaid, a different set of plan appeal rules applies, so check your plan notice for its deadline.5

Federal rules cap how long the plan can take: no more than 30 calendar days for a standard appeal and 72 hours for an expedited one, counted from when the plan receives it, and the plan must decide as fast as your health condition requires. Either timeframe can be extended by up to 14 calendar days if you ask for the extension, or if the plan shows the state that it needs more information and how the delay is in your interest. If the plan extends on its own, it must give you written notice of the reason within 2 calendar days and tell you that you can file a grievance if you disagree.4 If waiting could harm your health, ask for the expedited track; the plan's notice must tell you when an appeal can be expedited and how to request it.7

Once the plan upholds its denial, you may request a state fair hearing within 120 days from the date of the plan's Notice of Appeal resolution letter.2,4 Keeping your coverage runs on a much shorter clock. Under federal rules, your continued benefits end if you do not request the fair hearing and continuation within 10 calendar days after the plan sends its appeal decision, so a member with 120 days to file may have only 10 days to keep services running. If the plan's decision is upheld, it may, consistent with state policy, recover the cost of the services furnished while the appeal and hearing were pending, to the extent you received them only because benefits continued.4

How to request a Missouri Medicaid fair hearing

MO HealthNet appeals and fair hearings are decided by the Benefit Hearings Unit of the Division of Legal Services (DLS) within the Missouri Department of Social Services.2 For a Family Support Division decision, FSD's Hearings Information sheet (IM-4) says to complete a Hearing Request and send it, with any supporting documents, by email to IMHearing.FSD@dss.mo.gov, by fax to 573-526-4554, by mail to Family Support Division, PO Box 2700, Jefferson City, MO 65102, or in person at a local FSD Resource Center.2 The sheet names no telephone route, so use one of those four rather than relying on a phone call to meet your deadline.2

The Benefit Hearings Unit itself is reached through three regional offices:

• Central Missouri: PO Box 1527, Jefferson City, MO 65102. Phone: 573-751-0335.2
• Western Missouri: 8800 E. 63rd St., Suite 520-B, Raytown, MO 64133. Phone: 816-325-5918.2
• Eastern Missouri: 8501 Lucas and Hunt, Suite 110, St. Louis, MO 63136. Phone: 314-877-2072.2

The Division of Legal Services does not represent individuals, so it cannot act as your advocate at the hearing.2 For general questions, the Family Support Division (FSD) Information Center general line is 1-855-373-4636.2

Learn More

Find personalized help navigating a Missouri 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.