If your New Mexico Medicaid was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is decided., In New Mexico, an appeal of a Medicaid action goes to the New Mexico Health Care Authority (HCA) Office of Fair Hearings (OFH), where an Administrative Law Judge (ALJ) who had no part in the decision hears the case, usually by phone.

In This Guide

What you can appeal in New Mexico 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 federal Medicaid statute (42 USC 1396a(a)(3)) requires New Mexico's Medicaid plan to grant 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 acted erroneously or made an adverse determination.

In New Mexico, the Office of Fair Hearings registers appeals of adverse actions across every public-assistance category, and an adverse action can include a denial, closure, reduction, sanction, or delay of benefits. In practice, that means you can appeal:

  • An application denial (income, assets, household, or documentation)
  • A termination or reduction of eligibility or a covered service
  • A cut in authorized hours of personal care or other long-term services
  • 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 program. Any applicant or beneficiary can request a hearing, and so can an attorney, guardian, or authorized representative acting on their behalf.

New Mexico Medicaid appeal deadlines that decide your case

Three deadlines govern a New Mexico Medicaid appeal, and they are not the same number: the request window, the continuation window, and the managed-care windows.

The request window: 90 days

Start with what the federal rule actually does. Under 42 CFR 431.221(d), the agency must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a hearing. Those 90 days are a ceiling on the window a state may offer, not a floor you are guaranteed, so a state is free to set a shorter reasonable window and that shorter deadline binds. New Mexico has not set one: the HCA states that most appeals must be requested no later than 90 days from the date the action was taken, and there is no shorter state-specific Medicaid fair-hearing deadline here. So the full 90 days is the operative deadline here.

The continuation window: before the date of action

This window keeps your benefits flowing while you appeal, and it is earlier than the 90-day request deadline. It is covered in the next section.

The managed-care windows: 60 days, then 90 to 120 days

If your denial came from a Turquoise Care health plan, you have 60 calendar days from the date on the plan's notice to file an internal appeal with the plan. After the plan resolves that appeal against you, the state must give you no fewer than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing; the exact number within that band is set by the state.

One more deadline protects renewals. If New Mexico ended your coverage 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, New Mexico may offer the same window but is not required to, so ask ISD.

How to keep your benefits during a New Mexico Medicaid appeal

Continuing benefits during an appeal is called aid paid pending, and it is not automatic: you have to ask for it, and you have to ask in time. 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 reduce or terminate your services until a decision is rendered after the hearing. The trigger is the date of action printed on your notice, not the 90-day request window. Miss that date and continuation under 431.230 no longer applies. A separate rule can still help: under 42 CFR 431.231, if you request the hearing no more than 10 days after the date of action, the agency may reinstate your services, so ask about reinstatement rather than assuming the door has closed.

In New Mexico, the Office of Fair Hearings does not administer benefits itself; whether your benefits continue at the prior level is decided through the Income Support Division or the Medical Assistance Division. You are not required to keep benefits running during the appeal, and the HCA warns that if you do and then lose, you may have to pay back benefits issued to you. Federal rules bound what can be taken back: under 42 CFR 431.230(b), the agency may recover the cost of the services furnished solely by reason of the continuation, not everything Medicaid paid for while your appeal was pending.

Managed care (MCO) appeals in Turquoise Care

Most New Mexico Medicaid members get their care through Turquoise Care, the state's mandatory managed-care program (formerly Centennial Care 2.0). As of July 1, 2024, members choose among four health plans, also called Managed Care Organizations (MCOs): Blue Cross Blue Shield of New Mexico, Molina Healthcare, Presbyterian Health Plan, and United Healthcare Community Plan. When a plan denies care, you appeal to the plan before you reach a state fair hearing. These rules come from the federal managed-care regulations at 42 CFR Part 438.

What counts as a plan denial

An adverse benefit determination 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. Under 42 CFR 438.404, the plan must give you timely, written notice of that determination, and 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.

The internal appeal and exhaustion

You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, which can be requested orally or in writing. The plan has only one level of appeal, and you must normally exhaust it before requesting a state fair hearing. The exception sits in the same regulation: if the plan misses the notice or timing rules for that appeal, you are deemed to have exhausted it and may go straight to a state fair hearing.

How fast the plan must decide

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. Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

Then the state fair hearing

The Office of Fair Hearings registers Managed Care Organization actions, so once the plan upholds its denial you can bring that decision to a state fair hearing. You then have 90 to 120 days, set by the state, to request it. One New Mexico rule to note: an appeal involving a Managed Care Organization must be withdrawn in writing, not by phone.

How to request a fair hearing in New Mexico

You request a hearing directly from the Office of Fair Hearings. There are five ways to file, and any one of them works:

When you ask for a hearing, give your name and case number, the reason you are asking and the assistance that was reduced, closed, or denied, and a phone number where the office can reach you.

After the hearing, an Administrative Law Judge submits a recommendation to the appropriate Division Director, who issues the final decision. If you disagree with that final decision, you have 30 days from its date to appeal to the New Mexico District Court.

Frequently Asked Questions

When does the 90-day appeal clock start?

The clock runs from the date of the action, which is printed on the notice the New Mexico Health Care Authority sends. Under 42 CFR 431.221(d), 90 days from the mailing of that notice is the longest window a state may allow, not a minimum every state has to give, and New Mexico allows the full 90. Always go by the date on your own notice. If the denial came from a Turquoise Care health plan, a separate 60-calendar-day clock to file the plan's internal appeal starts from the date on the plan's notice.

I missed the date of action. Is it too late to keep my benefits?

Continuing benefits at the prior level (aid paid pending) requires requesting the hearing before the date of action on your notice; under 42 CFR 431.230(a), that is the trigger. If you request the hearing after the date of action, you can still appeal: New Mexico's request window runs the full 90 days that 42 CFR 431.221(d) permits a state to allow, counted from the date of the action. Check that date on your notice. You may also still get your services back: under 42 CFR 431.231, if you request the hearing no more than 10 days after the date of action, the agency may reinstate them for the length of the appeal. Past that 10-day mark the appeal goes forward, but your services do not continue at the prior level.

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

No. Any applicant or beneficiary can request and present a fair hearing on their own, and an attorney, guardian, or authorized representative may act on their behalf if you want help. Representation often helps most with level-of-care and prior-authorization disputes, where the case turns on documentation from the treating provider.

What is the difference between an MCO appeal and a state fair hearing?

A Managed Care Organization (MCO) appeal is the internal appeal you file with your Turquoise Care plan, and it is the required first step; the plan must resolve a standard appeal within 30 days or an expedited appeal within 72 hours. Only after the plan upholds its denial can you request a state fair hearing before an Administrative Law Judge, and you then have 90 to 120 days, set by the state, to ask for it.

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 Mexico Medicaid: A Guide for Seniors and FamiliesNew Mexico Medicaid (Centennial Care) covers long-term care for seniors: 2026 income caps, the Income Diversion Trust rule, asset limits, and how to apply. MedicaidYour Guide to New Mexico Medicaid Income and Asset LimitsNew Mexico Medicaid income limits 2026: $2,982/month for long-term care, about $1,835 under MAGI for adults under 65, plus asset rules and how to apply. MedicaidHow to Apply for New Mexico Medicaid (Centennial Care)How to apply for New Mexico Medicaid (Turquoise Care) for long-term care in 2026: YesNM channels, the Miller Trust gate, documents, timelines, and appeals.

Find personalized help navigating a New Mexico 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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