Utah Medicaid Appeals and Fair Hearings: How to Appeal

If your Utah Medicaid coverage was denied, cut, or terminated, you have the right to appeal and request a fair hearing.1 That right comes from federal Medicaid law, and it carries a second protection: if you request the hearing before the date your notice says the action takes effect, your benefits can keep flowing until a decision is reached after the hearing.2

In This Guide

• What you can appeal in Utah Medicaid
• Utah Medicaid appeal deadlines that decide your case
• How to keep your benefits during a Utah Medicaid appeal
• Which Utah office decides your appeal
• Managed care (ACO) appeals: exhaust your plan first
• How to request a Utah Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in Utah Medicaid

Federal law gives Medicaid 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, Utah's included, to offer a hearing to anyone whose claim for assistance is denied or is not acted on with reasonable promptness. The implementing rule at 42 CFR 431.220 extends that right to anyone who believes the agency acted in error, denied a claim for eligibility or for covered services, set their share of costs, or failed to act promptly, as well as to nursing facility residents facing a transfer or discharge they believe is wrong and to managed care plan enrollees. The one stated exception: the agency need not grant a hearing when the only issue is a federal or state law that requires an automatic change affecting some or all beneficiaries.1

In practice, that means you can appeal:

• An application denial based on income, assets, household composition, or documentation
• A termination or reduction of eligibility or of a covered service
• A renewal or recertification denial
• A prior authorization decision
• A spend-down determination, or the premiums and cost sharing you are charged
• A nursing facility's decision to transfer or discharge you
• A disability determination made for a Medicaid or CHIP decision
• A managed care plan's denial, reduction, suspension, or termination of a service

Utah Medicaid appeal deadlines that decide your case

Three deadlines govern a Utah Medicaid appeal, and they are not the same number.

Under 42 CFR 431.221(d), the state must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a hearing.3 That 90 days is a ceiling on the state's window, not a minimum every state must give.3 Utah allows the full federal maximum: a member appealing a Medicaid or CHIP eligibility or disability decision files the hearing request within 90 days of the date on the notice.4 Count from the date printed on your notice, not the day it reached you, and if your notice names an earlier deadline, that is the one to meet.

A second deadline keeps your benefits flowing: request the hearing before the date of action stated on your notice.2

A third set of deadlines applies to managed care. If your denial came from an Accountable Care Organization (ACO), you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.5 After the plan resolves that appeal against you, the state must allow no fewer than 90 and no more than 120 calendar days from the date of the plan's resolution notice to request a state fair hearing; the exact number within that band is set by the state.6

One more deadline protects renewals. If Utah ended your coverage only because you did not return a renewal form on time, you may not 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. Ninety days is the federal minimum, and a state may allow longer. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through SSI, age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Utah may offer the same window but is not required to, so ask DWS.7

How to keep your benefits during a Utah Medicaid appeal

Continuation of benefits during an appeal is often called "aid paid pending," and it is governed by 42 CFR 431.230. Under 42 CFR 431.230(a), if the agency sent the required 10-day (or 5-day) advance notice and you request the hearing before the date of action stated on that notice, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless 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.

Continuation is not automatic. A request made after the action has already taken effect does not continue benefits under this rule. A separate provision, 42 CFR 431.231, lets the agency reinstate services when you request a hearing not more than 10 days after the date of action.2 That reinstatement path is the "10-day" number people remember, and it is different from continuation. Reinstated services then continue until the hearing decision unless the hearing finds the only issue is one of federal or state law or policy.2

If the agency cut your services without sending the required advance notice at all, reinstatement is not optional. Under 42 CFR 431.231(c), the agency must reinstate and continue your services until the hearing decision if you request a hearing within 10 days of receiving the notice of action (counted as 5 days after the date on the notice unless you show it arrived later) and the agency finds the action did not result from applying federal or state law or policy.2

If your benefits continue and the action is later upheld at the hearing, 42 CFR 431.230(b) permits the agency to recoup the cost of the services furnished solely because benefits were continued.2

When an adverse-action notice arrives, find the date of action, request the hearing before that date, and put your request to continue benefits in writing. You have to ask for it.

Which Utah office decides your appeal

Utah splits appeals by dispute type. The Utah Office of Administrative Hearings (OAH) hears benefit, service, and disability-determination disputes, including disputes of disability decisions made by the Medical Review Board. Medicaid and CHIP eligibility fair hearings are filed instead with the Utah Department of Workforce Services (DWS), Division of Adjudications.4

Utah's OAH allows the full federal maximum of 90 days for an eligibility or disability decision, but 90 days is a ceiling rather than a guaranteed minimum, so the deadline printed on your own notice is the one to meet.3,4 The 60-day managed care window is the federal internal-appeal deadline.5

Managed care (ACO) appeals: exhaust your plan first

Utah delivers Medicaid managed care through four Accountable Care Organizations (ACOs): Health Choice Utah, Healthy U, Molina Healthcare, and SelectHealth Community Care. Members who live in Utah, Salt Lake, Davis, Weber, Box Elder, Cache, Iron, Morgan, Rich, Summit, Tooele, Wasatch, or Washington County must choose a plan.4 The federal rules for Medicaid managed care plans, at 42 CFR Part 438, set the appeal steps below.

A member or provider disputing an action taken by an ACO must complete that organization's internal appeal before filing a hearing request with OAH.4 You have 60 calendar days from the date on the adverse benefit determination notice to file that internal appeal, which can be requested orally or in writing, and the plan has one level of appeal.5

Under 42 CFR 438.404, the plan must give you timely and adequate written notice of an adverse benefit determination, such as a denial of a service authorization, a termination, suspension, or reduction of a service already authorized, a denial of payment, or a decision not made in time. That notice must explain the reasons, your right to free copies of the records behind the decision (including the medical-necessity criteria used), how to appeal and request a state fair hearing, when and how to request an expedited appeal, and how to ask that your benefits continue during the appeal.8

The plan must decide your appeal as fast as your health condition requires, within a state-set deadline that federal rules cap 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. Either deadline can be extended by up to 14 calendar days if you request the extension or the plan 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 give you written notice of the reason within 2 calendar days and tell you that you can file a grievance if you disagree.6 Your plan's denial notice must tell you when an expedited appeal is available and how to ask for one.8

If the plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving your appeal, federal rules treat the plan appeal as exhausted and you may go straight to a state fair hearing.6 Utah's OAH states its exhaust-first rule without mentioning that exception, so keep a record of when you filed the plan appeal and when the plan's deadline passed.4 That turns on how the plan handles your appeal, so file the plan's internal appeal within 60 calendar days of the date on the determination notice either way.5 Once the plan upholds its denial, you then have 90 to 120 days, the exact number set by the state, to request the hearing with OAH.6

If you want your services to continue while you wait, don't use that whole window. Under 42 CFR 438.420, continued benefits end if you don't request the state fair hearing and continuation of benefits within 10 calendar days after the plan sends its decision on your appeal. Earlier, at the plan-appeal stage, benefits continue only when the appeal is about ending, suspending, or reducing a service that was already authorized and ordered by an authorized provider, the authorization period has not run out, you filed the appeal on time, and you asked for continuation by the later of 10 calendar days after the plan sent its denial notice or the date the change takes effect. If the plan's decision is upheld in the end, it may recover the cost of the services you received only because benefits continued.6

How to request a Utah Medicaid fair hearing

Once you know which office handles your dispute, the request itself is straightforward. Match your notice to the right path.

For a benefit, service, or disability-determination dispute, complete the State Fair Hearing Request Form and email it as an attachment to utmedicaidhearings@utah.gov, or mail it to the Department of Health and Human Services, Office of Administrative Hearings, PO Box 143105, Salt Lake City, UT.4 The Office of Administrative Hearings page carries the form and the current filing instructions.

For a Medicaid or CHIP eligibility dispute, file your fair hearing with the Department of Workforce Services, Division of Adjudications, rather than with OAH.4 Check which office your notice names before you file.

For a managed care denial, file your plan's internal appeal first; then, if the plan upholds the denial, request the state fair hearing with OAH within the 90-to-120-day window, or within 10 calendar days of the plan's decision if you want your services to continue.6

Whatever the path, request continuation of benefits in writing at the same time you file, and do it before the date of action on your notice if you want your coverage to hold.2 For a managed care plan's decision, the 10-day windows described above apply instead.6

Learn More

Find personalized help navigating a Utah 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.