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 gives Medicaid applicants and beneficiaries 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 with reasonable promptness, and 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously, denied a claim for eligibility or services, or did not act on a claim promptly, including a prior-authorization decision or a change in the amount or type of services. The right has one stated exception: 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.

In New Mexico, a fair hearing challenges an adverse action taken by the HCA, which can be a denial, closure, reduction, sanction, or delay of benefits, and the Office of Fair Hearings also registers Managed Care Organization actions. 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. For an action the HCA itself took, New Mexico applies that full federal window: the Office of Fair Hearings says most appeals must be requested no later than 90 days from the date the HCA or its agent took the action. A decision by your Turquoise Care health plan runs on different clocks, covered below, and this 90-day window does not start from the plan's original notice.

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 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, federal rules require the state to 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, and the state picks the number. New Mexico's rule sets it at the low end: request a standard hearing within 90 days of the date of the plan's final appeal decision, or an expedited hearing within 30 calendar days of the date of that decision letter.

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 the HCA.

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. If the agency cut your services without the advance notice it owed you, reinstatement is not optional: under 42 CFR 431.231(c), 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 action did not result from applying federal or state law or policy, the agency must reinstate your services until the hearing decision.

In New Mexico, you may be able to keep receiving benefits at the prior level during the appeal, but you are not required to, 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. In New Mexico, follow an oral request with a written one within 13 calendar days. If the plan is cutting or ending a service you already receive, ask for continuation at the same time: New Mexico's rule requires you to request the plan appeal and continuation of the benefit within 10 calendar days of the plan mailing its notice, or before the date the notice says the benefit will end, and continuation is open only to a member receiving that benefit when the notice goes out. 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. If your health can't wait that long, ask for the expedited track; the plan's notice has to tell you when an appeal can be expedited and how to request it.

Then the state fair hearing

The Office of Fair Hearings registers Managed Care Organization actions, so once the plan's appeal decision fails to fully reverse its action, you can bring it to a state fair hearing. You then have 90 days from the date of the plan's final appeal decision to request a standard hearing, or 30 calendar days from the decision letter for an expedited one. If your benefit continued during the plan appeal, you don't have to ask again when you request the hearing, because the plan keeps it going; but if the hearing upholds the plan's action, you could owe the cost of the benefit continued during the plan appeal and the hearing. 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 still goes forward, but continuation is generally gone; the exception is an action taken without the advance notice the agency owed you, where the 10 days run from when you received the notice and reinstatement is required.

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. In New Mexico you then have 90 days from the plan's final appeal decision to ask for a standard hearing, or 30 calendar days for an expedited one.

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 long-term care under Turquoise Care (formerly Centennial Care): the 2026 income cap, Income Diversion Trust, asset limits, 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 (Turquoise 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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