New York Medicaid Appeals and Fair Hearings

If your New York Medicaid was denied, cut, or terminated, you have the right to appeal and request a State Fair Hearing, and you can often keep your benefits while the appeal is decided.1,2 The deadline that keeps your coverage in place is earlier than the deadline to file the hearing itself, so the date on your notice matters more than most people realize.

In This Guide

• What you can appeal in New York Medicaid
• The New York Medicaid appeal deadlines that decide your case
• How to keep your benefits during the appeal
• Managed care and MLTC appeals: appeal the plan first
• How to request a New York Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in New York Medicaid

Federal law guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency whenever a claim for medical assistance is denied, is not acted on with reasonable promptness, or is reduced or terminated.1 In New York, that hearing is the State Fair Hearing, and it reaches across the whole program.

You can request a State Fair Hearing when New York denies, reduces, suspends, or terminates your Medical Assistance (New York's name for Medicaid) or a covered service.3 In practice, that covers:

• An application denial (income, resources, disability, or documentation)
• A termination or reduction of your Medicaid eligibility
• A cut to the hours or scope of a service you already receive, such as personal care or home care
• A prior authorization denial or a denial of a specific service or item
• A denial, reduction, or termination made by your Medicaid managed care or Managed Long Term Care (MLTC) plan

The right to a hearing is the same whether the action came from the local district that runs your case or from a managed care plan. What changes between those two paths is the process you follow to get there, and the deadlines are covered next.

The New York Medicaid appeal deadlines that decide your case

New York sets two request windows for a State Fair Hearing, and which one applies depends on who took the action.

For a direct, fee-for-service Medicaid action, when the decision came directly from your local district or the state rather than a managed care plan, you must request the State Fair Hearing within 60 days from the date of the notice.3 Federal law allows states a reasonable time not to exceed 90 days from the date the notice is mailed, and New York uses 60, so do not assume you have the full federal 90.4 Read the date off your own notice and count from there.

For a managed care or Managed Long Term Care (MLTC) action, you cannot go straight to a State Fair Hearing. You first request an appeal from the plan and wait for its Final Adverse Determination. Once you have that determination, you have no less than 120 days from its date to request the State Fair Hearing.3

There is also a separate, earlier deadline that has nothing to do with whether you eventually win: the aid continuing deadline that keeps your benefits flowing while the appeal is pending. It is short, and it is covered in the next section.

How to keep your benefits during the appeal

In New York this protection is called aid continuing, and it is not automatic. You have to request the hearing in time to trigger it.

Your Medical Assistance and services stay in place until the Fair Hearing decision if you request the hearing before the effective date printed on your notice.3 If the notice was not sent before that effective date, you still keep aid continuing as long as you request the hearing within 10 days of the postmark date on the notice.3 This implements the federal maintaining-services rule, which bars the agency from cutting or ending your services before a hearing decision when you request the hearing before the date of action.2

Aid continuing carries one cost worth understanding. If you receive aid continuing and then lose the hearing, you may have to repay the Medical Assistance you received while you were waiting for the decision.3 That does not make aid continuing a bad choice for most families, but it is a reason to gather your documentation and take the hearing seriously.

The practical takeaway: when an adverse notice arrives, find the effective date on it, request the hearing before that date, and ask for aid continuing when you file. The 60-day and 120-day request windows keep your appeal alive, but only the aid continuing deadline keeps your coverage running while you wait.

Managed care and MLTC appeals: appeal the plan first

Many New Yorkers on Medicaid get their long-term care through a Managed Long Term Care (MLTC) plan or an integrated Medicaid Advantage Plus (MAP) plan. When one of those plans, or a mainstream Medicaid managed care plan, denies or reduces a service, the appeal runs through the plan before it can reach a State Fair Hearing. These rules come from the federal managed care regulations at 42 CFR Part 438.

You must first request a Plan Appeal from your plan and receive its Final Adverse Determination before you can request a State Fair Hearing.3 The federal filing window for that internal plan appeal is 60 calendar days from the date on the plan's adverse benefit determination notice.5 That notice must tell you how to appeal, how to ask for an expedited appeal, and how to keep your benefits during the appeal.6

The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours, though either timeframe can be extended by up to 14 calendar days in limited circumstances.7 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or your ability to keep functioning.

If the plan misses its own notice or timing requirements, you are treated as having exhausted the plan appeal, and you can go straight to a State Fair Hearing.3 After you have the Final Adverse Determination, you have at least 120 days to request the hearing under New York's rule, which sits inside the federal window of 90 to 120 days that states set for managed care fair hearings.3,7

The participating MLTC and MAP plans whose internal appeal you must exhaust are listed in the New York State Department of Health Managed Long-Term Care Plan Directory.8 New York Medicaid Choice, the state's enrollment broker, can help you identify your plan at 1-888-401-6582.8

How to request a New York Medicaid fair hearing

New York runs Medicaid fair hearings through a single statewide office: the Office of Temporary and Disability Assistance (OTDA), Office of Administrative Hearings (OAH). Managed care and MLTC disputes are handled by OAH's dedicated Managed Care Hearing Unit, which uses a different mailing address than general Medicaid cases.3

You can request a State Fair Hearing in any of five ways:3

• Online, through the OTDA Fair Hearing online request form at errswebnet.otda.ny.gov
• By phone, at the statewide toll-free line 1-800-342-3334 (the New York City emergency-only line is 1-800-205-0110)3
• By fax, to 518-473-6735
• By mail, using the printable Fair Hearing Request Form
• In person, in New York City at 5 Beaver Street, or in Albany at 40 North Pearl Street

Where you mail a written request depends on the type of case. General Medical Assistance requests go to OTDA/OAH, P.O. Box 1930, Albany, NY 12201-1930. Requests about health benefits or services under a managed care or MLTC plan go to the Managed Care Hearing Unit, P.O. Box 22023, Albany, NY 12201-2023.3 Keep a copy of whatever you send, and if you want aid continuing, say so clearly in the request.

Learn More

Find personalized help navigating a New York 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.