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 the date of action printed on your notice, not the longer window 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 guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act requires each state plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted on promptly, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.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 denial or a level-of-care determination
• A managed care health plan's denial, reduction, suspension, or termination of a service

The right reaches across the program, from the eligibility decision at your front door to a service cut years into coverage. Because federal rules let you keep your benefits while an appeal is pending when you request the hearing in time, an existing recipient does not lose coverage just for appealing.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 applies the federal 90-day window measured from the date the adverse-action notice is mailed.2 Federal law caps this deadline at 90 days from the mailing date and bars a state from requiring the request any sooner, so 90 days is both the ceiling and Missouri's stated window for fee-for-service decisions.3 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

The deadline that keeps your benefits flowing is separate and earlier. It is not the 90-day or 120-day filing window; it is the date of action on your notice, covered in the next section.

One more deadline protects renewals. If your MO HealthNet coverage was ended only because you did not return a renewal form or requested information on time, you do not always have to reapply: under 42 CFR 435.916, if you submit the renewal form or the missing information within 90 days after the termination date, the agency must reconsider your eligibility without a new application.6

How to keep your benefits during a Missouri Medicaid appeal

Missouri continues benefits during an appeal under the federal continuation rule at 42 CFR 431.230(a), sometimes called aid paid pending, but only if you request the hearing before the date of action on your notice.2

Under 42 CFR 431.230(a), 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, unless the only issue is one of federal or state law or policy.2 The trigger is the date of action, not the full length of the filing window.

Continuation is not automatic, so you have to ask for it in writing. When an adverse-action notice arrives, find the date of action printed on it, request your hearing before that date, and state in writing that you want your benefits to continue during the appeal.

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 That risk applies only where the notice warned of it, so read your notice.

Managed care (MCO) appeals: exhaust your plan first

Most MO HealthNet participants who use managed care receive care through a health plan, and a managed care organization (MCO) is that health plan. 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, which includes a denial or limited authorization of a service, a reduction or termination of a previously authorized service, a denial of payment, or a failure to act within required timeframes. The 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

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 must complete it before requesting a state fair hearing.

The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours of receiving it. Either timeframe can be extended by up to 14 calendar days if you request the extension or the plan shows the state that more information is needed and the delay is in your interest.8 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

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

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 Your appeal request may be made orally or in writing to the agency; you do not need a special form to start it.2

The Benefit Hearings Unit works through three regional offices. Send your written request, or call, using the office for your part of the state.

• 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

After you file, the Benefit Hearings Unit sends a notice of hearing with a contact number at the top; use that number for questions about your specific case.2 The Division of Legal Services does not represent individuals, so it cannot act as your advocate at the hearing.2 For general questions about your case before a hearing is scheduled, 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.