New Jersey Medicaid Appeals and Fair Hearings

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.1 In many cases you can also keep your benefits running while the appeal is decided, but only if you ask in time.2

In This Guide

• What you can appeal in New Jersey Medicaid
• The New Jersey Medicaid deadlines that decide your case
• How to keep your New Jersey Medicaid benefits during an appeal
• Managed care (MCO) appeals: appeal your plan first
• How to request a New Jersey Medicaid fair hearing

What you can appeal in New Jersey Medicaid

Federal Medicaid law gives applicants and beneficiaries 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 each state's Medicaid plan, New Jersey's included, to offer a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness. The implementing regulation, 42 CFR 431.220, extends that right to anyone who believes the agency acted erroneously, denied a claim for eligibility or covered services, or issued a determination of their liability, and to managed care plan enrollees, nursing facility residents facing a transfer or discharge, and people disputing a preadmission screening (PASRR) decision.1

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
• A nursing facility's decision that you must be transferred or discharged

The right reaches across the whole program, from an application at your county office to a service your health plan refuses to cover. It has one stated limit: the agency need not grant a hearing when the only issue is a federal or state law that automatically changes benefits for some or all beneficiaries.1 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 operative date is the one printed on your own notice of action, and the honest answer is that no other number should drive your planning. The 90 days you may have seen quoted is a federal ceiling on states, not an entitlement of yours: 42 CFR 431.221(d) requires a state to allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a fair hearing. That is the longest window a state may offer, never a floor you can count on, and a shorter state deadline is the one that applies to you.3 This guide does not state a New Jersey figure for eligibility appeals because it has no New Jersey source it can quote for one, and a number nobody can source is worse than no number. So treat the date on your notice as your deadline, and if the notice is unclear or missing, call your County Welfare Agency (County Board of Social Services) and ask what window applies to your case before the date passes.

For a managed care service denial, the clock 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.4,5 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.4 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.6

The continuation-of-benefits deadline is the shortest and most valuable of the three, and it runs differently depending on who acted. For a managed care service denial it is 10 calendar days from the plan's letter; for an eligibility action it is not a flat count of days at all, but the date of action printed on your notice. The next section covers both.

One more rule protects renewals. If New Jersey ended your coverage only because you did not return a renewal form on time, you may not have to appeal at all: under 42 CFR 435.916, if you submit the renewal form within 90 days after the termination date (or a longer period, if the state elects one), the agency must reconsider your eligibility in a timely manner without a new application. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through SSI, age 65 or older, blindness or disability, long-term care, a Medicare Savings Program, or the medically needy pathway, New Jersey may offer the same window but is not required to, so ask DMAHS or your County Welfare Agency.7

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. Don't count on it happening automatically. Ask for it explicitly, and request your hearing before the action takes effect, which is what keeps coverage running unbroken. Miss that date and a separate federal rule, 42 CFR 431.231, still lets the agency reinstate your services if you request a hearing no more than 10 days after the date of action.2

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. That protection gives way only when both halves of a narrow exception are met: the hearing determines that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that services will be terminated or reduced pending the decision.2 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.4 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.2 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.2 If the agency cut your services without the advance notice it owed you, the same rule goes further: it must reinstate them until the hearing decision if you request a hearing within 10 days of receiving the notice (counted as 5 days after the date on the notice, unless you show it reached you later), and the action did not result from applying federal or state law or policy.2

Managed care (MCO) appeals: appeal your plan first

Many 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).4 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, when and how to ask for an expedited appeal, and how to request that your benefits continue, and you can ask for free copies of the records and medical-necessity criteria behind the decision.8

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.4,5 If you have both Medicare and Medicaid and your plan is an applicable integrated plan, its plan-level appeals follow a different federal rule (42 CFR 422.629 through 422.634) rather than this 60-day one, so take your deadline from the plan's notice.5 The plan has only one level of appeal, and in the ordinary case you must wait for its notice upholding the denial before requesting a Medicaid fair hearing. There is one federal exception worth knowing: if the plan fails to follow the federal notice and timing requirements for resolving appeals (42 CFR 438.408), you are deemed to have exhausted its appeal process anyway, and you may go straight to a fair hearing.6

The plan is on its own clock to decide. It must resolve your appeal as quickly as your health condition requires, and federal rules cap the state's deadline for the plan at 30 calendar days for a standard appeal and 72 hours for an expedited one, counted from when the plan receives it. Those are ceilings, not time the plan is entitled to use. The plan can extend either window by up to 14 calendar days if you ask for the extension, or if it shows the state that it needs more information and how the delay is in your interest. If the plan extends without your asking, it must make reasonable efforts to give you prompt oral notice, send written notice of the reason within 2 calendar days, and tell you that you can file a grievance if you disagree.6 If waiting could harm your health, ask for the expedited track; your denial notice must explain when an appeal can be expedited and how to request it.8

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.4 If you already receive the service and want it to continue during the hearing, don't use that full window: federal rules end continued benefits if you fail to request the fair hearing and continuation within 10 calendar days after the plan sends its appeal decision. Wait the full 120 days and you keep the hearing but lose the coverage in the meantime.6

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 contested cases for state agencies and issue initial 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 grant it and transmit your case to the OAL as a contested case.4 The ALJ's ruling is not the last word. In most cases the initial decision goes to the agency head, who may affirm, modify, or reject it within 45 days of receiving it (a time frame that can be extended for good cause), and any change must be explained in writing. If no final decision issues within those 45 days and the time frame was not extended, the initial decision becomes the final decision, so silence after the hearing does not mean you lost.4

To request a fair hearing on an eligibility decision, DMAHS's published fair hearing notice says to 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. That notice was written for NJ FamilyCare notices issued in a specific 2025 window, so confirm the filing address printed on your own denial notice before you rely on it.4 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.4

The same DMAHS notice states that if your application was denied, you can 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; confirm with your County Welfare Agency that this still applies to your case.4 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.

Learn More

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.