If your New Jersey Medicaid or NJ FamilyCare coverage was denied, cut, or terminated, you have the right to appeal and request a fair hearing. In many cases you can also keep your benefits running while the appeal is decided, but only if you ask in time.

In This Guide

What you can appeal in New Jersey Medicaid

Federal Medicaid law guarantees every applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires New Jersey's Medicaid plan to give a hearing to anyone whose claim for medical assistance is denied or is not acted on promptly, and 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.

In practice, that means you can appeal:

  • A denial of your NJ FamilyCare or New Jersey Medicaid application (income, assets, household, or documentation)
  • A termination or reduction of your eligibility or covered services
  • A cut to the hours or amount of a service you already receive, such as personal care
  • A prior authorization denial or a level-of-care determination
  • A managed care plan's denial, reduction, suspension, or termination of a service

The right reaches across the whole program, from an application at your county office to a service your health plan refuses to cover. What changes from one situation to the next is the deadline and the path, and those are what the rest of this guide sorts out.

The New Jersey Medicaid deadlines that decide your case

Deadlines, not arguments, are what most often cost a family its coverage. The window that applies to you depends on who made the decision.

For an eligibility decision, the clock runs up to 90 days. Under 42 CFR 431.221(d), the state must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a fair hearing. That 90-day federal ceiling is the deadline that governs an application denial or an eligibility termination in New Jersey; no New Jersey source we cite sets a shorter one. Read the deadline off your own notice and do not wait, but you have real time to act.

For a managed care service denial, the clock is shorter and runs in two steps: 60 days, then 120 days. You have 60 calendar days from the date on the plan's denial letter to file the plan's internal appeal., If the plan upholds its denial, you then have 120 calendar days from the date of the internal-appeal denial letter to request a Medicaid fair hearing. That 120-day figure sits inside the federal band, which requires states to allow no fewer than 90 and no more than 120 days after the plan's decision.

The continuation-of-benefits deadline is the shortest and most valuable, at 10 days, and it is covered in the next section.

One more rule protects renewals. If New Jersey ended your coverage only because you did not return a renewal form or requested information on time, you may not have to appeal at all: 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.

How to keep your New Jersey Medicaid benefits during an appeal

Keeping your benefits during the appeal, often called aid paid pending, is the protection families most often lose by acting a day too late. It is never automatic. You have to request it, and you have to request it before the action takes effect.

The federal rule sets the trigger. Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date of action stated on that notice, it 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. The trigger is the date of action on your notice, not a flat count of days after you read it.

Managed care works on a fixed count of days. If your denial came from a health plan and you already receive the service, you (or your provider acting for you) must request continuation of benefits within 10 calendar days of the date on the plan's denial letter, or by the end of the prior approved authorization, whichever is later. Miss that window and the service can stop while your appeal is still open.

There is a cost to weigh. If your benefits continue and the agency's action is later upheld, 42 CFR 431.230(b) permits the agency to recover the cost of the services furnished solely because your benefits kept running. A request made after the action already took effect does not trigger continuation, though a separate provision, 42 CFR 431.231, lets the agency reinstate services if you request a hearing within 10 days after the date of action.

The practical takeaway: when any denial or reduction notice arrives, find the date on it, request your hearing right away, and put your request to continue benefits in writing.

Managed care (MCO) appeals: appeal your plan first

Most New Jersey Medicaid members get their care through a managed care organization (MCO), a private health plan the state contracts with to run NJ FamilyCare benefits. The MCOs under contract in 2026 are Aetna Better Health of New Jersey, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan, and Wellpoint (formerly Amerigroup New Jersey). When your plan denies care, you appeal to the plan before you can reach a state fair hearing.

A plan denial has a formal name. Under 42 CFR 438.404, the plan must give you timely, written notice of an adverse benefit determination, its formal decision to deny, reduce, or end a service you asked for or already receive, or to deny payment for one. That notice must tell you how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue.

You cannot skip the internal appeal. You have 60 calendar days from the date on the denial letter to file the plan's internal (Stage 1 or Level 1) appeal., The plan has only one level of appeal, and you must wait for its result before requesting a Medicaid fair hearing. Going straight to a fair hearing without finishing the plan appeal gets the request dismissed.

The plan is on its own clock to decide. It must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours of receiving it. The plan can extend either window, the 30-day standard appeal or the 72-hour expedited appeal, by up to 14 calendar days if you request the extension, or if the plan shows the state that more information is needed and the delay is in your interest. Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or your ability to regain function.

Once the plan says no, the fair-hearing clock starts. You have 120 calendar days from the date of that internal-appeal denial letter to request a Medicaid fair hearing. If you already receive the service and want it to continue, remember the separate 10-day continuation window above.

How to request a New Jersey Medicaid fair hearing

In New Jersey, a Medicaid fair hearing is heard as a contested case by the Office of Administrative Law (OAL), an independent state agency whose administrative law judges (ALJs) hear cases for state agencies and issue decisions. You cannot file a hearing request directly with the OAL. The request goes to the Division of Medical Assistance and Health Services (DMAHS), which decides whether to transmit your case to the OAL as a contested case.

To request a fair hearing on an eligibility decision, send a written request stating that you disagree with the decision to the DMAHS Fair Hearing Unit, P.O. Box 712, Trenton, NJ 08625, or fax it to 609-588-2435, and include a copy of your eligibility notice. If your denial came from a managed care plan, finish the plan's internal appeal first, then request the fair hearing within the 120-day window described above.

If your application was denied, you can also reapply for Medicaid at any time while a fair hearing is pending, and you do not have to request a fair hearing in order to reapply. When a denial rests on a fixable gap, such as a missing document, calling your county office or the NJ FamilyCare help line first is often faster than a formal appeal.

Frequently Asked Questions

What should I include in my New Jersey Medicaid fair hearing request?

Send a written request that clearly states you disagree with the decision you received, and include a copy of the notice. For an eligibility decision, mail or fax it to the Division of Medical Assistance and Health Services (DMAHS) Fair Hearing Unit, P.O. Box 712, Trenton, NJ 08625, fax 609-588-2435. Keep a copy of everything you send and note the date, since your deadline runs from the date printed on your notice.

Can I reapply for New Jersey Medicaid instead of appealing a denial?

Yes. If your application was denied, you can reapply for New Jersey Medicaid at any time, and you do not have to request a fair hearing in order to reapply, so you can even do both at once while a fair hearing is pending. When a denial rests on a fixable gap like a missing document, reapplying or calling your county office is often faster than a formal appeal.

Do I need a lawyer for a New Jersey Medicaid fair hearing?

No. You can represent yourself at a fair hearing, and you may bring a family member, friend, or an attorney if you want help. Representation can be valuable for level-of-care, medical-necessity, and complex prior authorization disputes, where a letter from your treating provider often decides the case, but it is not required to file or to be heard.

What is the difference between a managed care appeal and a Medicaid fair hearing?

A managed care appeal is the internal appeal you file with your health plan, and it is the required first step for any service the plan denies. A Medicaid fair hearing is the state-level review, heard by an administrative law judge (ALJ) at the Office of Administrative Law (OAL), that you can request only after the plan upholds its denial. Eligibility denials skip the plan step and go straight to a fair hearing request filed with DMAHS.

Learn More

MedicaidHow to Appeal a Medicaid DenialDenied Medicaid? You can appeal, and one deadline decides whether your benefits keep flowing during the appeal. Know your fair-hearing rights and act fast. MedicaidNew Jersey Medicaid: The Complete GuideYour 2026 guide to New Jersey Medicaid (NJ FamilyCare): who qualifies, the MLTSS long-term-care path, 2026 income and asset limits, and how to apply. MedicaidHow to Apply for New Jersey MedicaidHow to apply for New Jersey Medicaid (NJ FamilyCare) in 2026: the online, phone, and county routes, plus what to bring, timelines, and how to appeal. MedicaidNew Jersey Medicaid Managed Long Term Services and Supports (MLTSS)New Jersey Medicaid MLTSS in 2026: how managed long-term care works, who qualifies (clinical and financial), the five health plans, and how to enroll. MedicaidNew Jersey Medicaid Estate RecoveryNew Jersey Medicaid estate recovery: the 55+ scope, the expanded-estate reach into non-probate assets, and the 20-day hardship-waiver window.

Find personalized help navigating a New Jersey 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.

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