Pennsylvania Medicaid Appeals: Keep Benefits, 30-Day Window

If your Pennsylvania 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.1,2 The number that governs your case is the deadline printed on your notice, and in Pennsylvania that window is short: 30 days from the date of the written notice, well below the federal 90-day ceiling.3

In This Guide

• What you can appeal in Pennsylvania Medicaid
• The deadlines that decide your Pennsylvania Medicaid appeal
• How to keep your benefits during a Pennsylvania Medicaid appeal
• Managed care (CHC) appeals in Pennsylvania
• How to request a fair hearing in Pennsylvania
• Frequently asked questions

What you can appeal in Pennsylvania Medicaid

Federal law guarantees every Medicaid applicant and recipient the right to a fair hearing before the state agency. Section 1902(a)(3) of the Medicaid statute (42 USC 1396a(a)(3)) and its implementing regulation at 42 CFR 431.220 require the state to grant a hearing to anyone whose claim for medical assistance is denied, not acted on promptly, or the subject of an adverse action.1

In Pennsylvania, Medicaid is called Medical Assistance, and appeals are heard by the Pennsylvania Department of Human Services (DHS) Bureau of Hearings and Appeals (BHA), a single statewide office. BHA hears more than 280 categories of DHS issues, including the denial, reduction, suspension, or termination of Medical Assistance benefits.3

That reach means you can appeal:

• An application denial for income, assets, or documentation
• A termination or reduction of eligibility or of a covered service
• A cut in authorized hours, such as personal care or home-care hours
• A prior-authorization denial or a level-of-care determination, including the appropriate level of care for a nursing-home resident
• A Community HealthChoices plan's denial, reduction, suspension, or termination of a service

The right runs across the whole program, not just applications. Because federal rules let you keep your benefits while an appeal is pending when you request the hearing in time, an existing recipient facing a termination does not lose coverage just for appealing.2

The deadlines that decide your Pennsylvania Medicaid appeal

Two deadlines govern a Pennsylvania appeal, and they are not the same date: the window to request a hearing, and the earlier window to keep your benefits flowing while the case is decided. The table below lines up every deadline in a Pennsylvania Medicaid appeal.

The request window

Under 42 CFR 431.221(d), the state must allow a reasonable time, up to 90 days from the date the notice is mailed, to request a hearing. The 90 days is the federal ceiling.3 Pennsylvania sets its operational window well below that: under 55 Pa. Code 275.3, the fair-hearing request must be filed within 30 days of the date of the written notice of the action.3 The deadline that governs you is the 30-day date tied to your notice, not the 90-day federal maximum.

Two extensions can save a late appeal. When no written notice was required or the agency simply failed to act, the window is 60 days. And when the agency never sent a notice of the action and of your right to appeal that it was required to send, you keep the right to appeal for up to 6 months from the date of the action.3

The continuation window

The window to keep your benefits flowing is earlier than the request window: it closes on the effective date printed on your notice, before the action takes effect. The next section covers how it works.

One more rule protects renewals. If your coverage ended only because you did not return a renewal form on time, you may not have to appeal or reapply at all: 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, Pennsylvania may offer the same window but is not required to, so ask your County Assistance Office.5

How to keep your benefits during a Pennsylvania Medicaid appeal

Continuation of benefits turns on the effective date on your notice, not the 30-day filing window. Two rules, one state and one federal, point to the same deadline.

The Pennsylvania rule

Under 55 Pa. Code 275.4, when you request the hearing within the advance-notice period, before the date the action takes effect, your assistance is continued pending the hearing decision unless you waive continuation.3 The trigger is the effective date printed on your notice, not the full 30-day filing window. If you wait past that effective date, your benefits generally stop while the appeal is decided, even though your appeal is still on time. Ask anyway if you are only a little late: under 42 CFR 431.231, a separate provision from the continuation rule, the agency may reinstate services when you request the hearing not more than 10 days after the date of action.2

The federal backstop

Pennsylvania's rule mirrors 42 CFR 431.230(a), under which the agency, having sent the required 10-day or 5-day advance notice, may not terminate or reduce services before a hearing decision when you appeal before the date of action. One carve-out: continuation does not apply when the sole issue in your case is a question of federal or state law or policy rather than the facts of your own situation.2

The trade-off to weigh first

Continued benefits are not automatically free. If the hearing decision goes against you, 42 CFR 431.230(b) permits the agency to recover the cost of the services furnished solely by reason of the continuation, meaning the benefits you kept only because you appealed.2 It is not a bill for everything you received while the appeal was pending. For most families that exposure is small next to losing coverage outright, which is why continuation is the default, but it is the reason the rules let you waive it. In managed care the same disclosure is required up front: under 42 CFR 438.404, the plan's notice must tell you how to request that benefits continue and the circumstances under which you may be asked to pay for them.6

Managed care (CHC) appeals in Pennsylvania

Pennsylvania delivers Medicaid long-term services and supports through Community HealthChoices (CHC), a mandatory managed-care program. Its participating managed care organizations (MCOs) are Keystone First Community HealthChoices, PA Health & Wellness, and UPMC Community HealthChoices.3 When a CHC plan denies a service or payment, 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

Under 42 CFR 438.404, the plan must give you timely written notice of an adverse benefit determination, which 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. That notice must explain how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue during the appeal.6

The internal appeal comes first

In Pennsylvania, a CHC participant challenging a plan decision must first pursue the plan's internal process: a Complaint, or a Grievance to reconsider a medical-necessity decision.3 Federal rules give you 60 calendar days from the date on the determination notice to file that internal appeal, which can be requested orally or in writing.7 You must complete this step before a state fair hearing, with one exception: if the plan misses the federal notice and timing rules on your appeal, the appeal is deemed exhausted and you may go straight to a fair hearing.4

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 extend by up to 14 calendar days if you request it or the plan shows the state that more information is needed and the delay is in your interest.4 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 fair hearing

After the plan issues its first-level Complaint or Grievance decision, you may request a fair hearing before BHA within 120 days from the mail date on that written decision.3 That 120-day window sits inside the federal band, which requires the state to allow no less than 90 and no more than 120 calendar days from the plan's notice of resolution.4 This managed-care clock is different from the 30-day fee-for-service window above.

How to request a fair hearing in Pennsylvania

A Pennsylvania appeal follows a set path, from the office that took the action to the Bureau of Hearings and Appeals. The steps below run in order.

File in writing with the office that acted

Except for SNAP, where an oral appeal is allowed, the appeal must be filed in writing with the DHS program office that took the action, typically your County Assistance Office. That office forwards your appeal to BHA, which dockets it and schedules a hearing.3

The hearing before an Administrative Law Judge

BHA schedules a hearing before an Administrative Law Judge (ALJ). The hearing is held by your choice of telephone or in person, and BHA decisions are typically issued within 90 days of the date the appeal is filed (60 days for SNAP).3

Where BHA is located

The Bureau of Hearings and Appeals is a single statewide office:

Bureau of Hearings and Appeals Pennsylvania Department of Human Services 2330 Vartan Way, Second Floor Harrisburg, PA 17110-9721 Phone: (717) 783-39503

After the decision

If you disagree with the ALJ's decision, you can ask the Secretary of Human Services to reconsider within 15 days of the decision, and you can petition Commonwealth Court within 30 days of the order.3

Learn More

Find personalized help navigating a Pennsylvania 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.