Virginia Medicaid Appeals: How to Request a Fair Hearing

If your Virginia Medicaid was denied, reduced, 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 The state deadline is short: Virginia gives you 30 days from receiving your notice to file.2 Federal law caps how long a state's window may run at 90 days, it does not guarantee you 90, so go by the date printed on your notice of action.2

In This Guide

• Key facts about Virginia Medicaid appeals
• What you can appeal in Virginia Medicaid
• Virginia Medicaid appeal deadlines that decide your case
• How to keep your benefits during a Virginia Medicaid appeal
• Managed care (MCO) appeals through Cardinal Care
• How to request a Virginia Medicaid fair hearing
• Frequently Asked Questions
• Learn More

What you can appeal in Virginia Medicaid

Federal law guarantees every Medicaid applicant and member the right to a fair hearing before the state agency whenever a claim for coverage is denied, is not acted on with reasonable promptness, or the agency takes an action the member believes is wrong.1 In Virginia, that hearing is provided by the DMAS Appeals Division, the state Medicaid agency unit that handles appeals for Medicaid and FAMIS (Family Access to Medical Insurance Security) members.2

You can appeal any action that denies, reduces, or terminates your coverage or services, including:

• An application denial based on income, assets, or household composition
• A termination or reduction of eligibility or a covered service
• A reduction in authorized service hours, such as personal care or attendant hours
• 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 runs across the whole program, and it applies whether your coverage is fee-for-service or through a managed care plan. A member can file the appeal, and so can a legal or authorized representative acting with the member's written consent.2

Virginia Medicaid appeal deadlines that decide your case

Two deadlines govern a Virginia Medicaid appeal, and they are different numbers. One sets how long you have to file; the other, an earlier one, decides whether your coverage keeps running while the appeal is pending.

The request window is 30 days in Virginia. Under 12VAC30-110-160, a Request for Appeal must be filed within 30 days of the date you receive your notice of action or adverse determination, and Virginia presumes you received the notice five days after the agency mailed it.2 Federal law caps this window at no more than 90 days from the date the notice is mailed, and Virginia's 30-day rule is a shorter operational deadline the federal ceiling permits.2

The continued-benefits window is separate and earlier: it falls before the effective date printed on your notice.

The managed care windows are 60 days, then 120 days: 60 days from the adverse benefit determination notice to request the plan's internal appeal,4 then 120 days from the plan's decision to request a DMAS fair hearing.2

If your coverage was terminated only because you did not return your renewal form, you may not have to appeal at all. Under 42 CFR 435.916(a)(3)(iii), 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, Virginia may offer the same window but is not required to, so ask DMAS.5

How to keep your benefits during a Virginia Medicaid appeal

Continued benefits, sometimes called aid paid pending, keep your coverage at its current level while the appeal is decided. They turn on an earlier deadline than the 30-day filing window, they are not automatic, and you have to file in time and ask for them.

If you file a grievance, an MCO internal appeal, or a DMAS appeal before the effective date of the adverse benefit determination, your coverage cannot be terminated or reduced for any reason that is the subject of the appeal until a decision is rendered.2 This is Virginia's implementation, at 12VAC30-120-420 and 12VAC30-110-100, of the federal continuation-of-benefits rule at 42 CFR 431.230. Under that federal rule, when the agency sends the required advance notice and you request a hearing before the date of action, the agency may not terminate or reduce services until a hearing decision is issued.3

The trigger is the date of the action, not the 30-day filing window. You can still file a valid appeal up to 30 days after receiving your notice, but filing after the action has already taken effect does not trigger continued benefits, so your coverage stops while the appeal is pending. If you are only a few days late, ask anyway: a separate federal rule, 42 CFR 431.231, lets the agency reinstate services when you request a hearing no more than 10 days after the date of action.3 To hold your coverage at the current level without a gap, request the appeal before the effective date printed on your notice and ask, in writing, that your benefits continue.

One caution before you ask. If the agency's action is later sustained, 42 CFR 431.230(b) permits the agency to recover the cost of the services furnished solely by reason of the continuation, not the cost of everything you received while the appeal was pending.3 If a managed care plan took the action, its notice has to spell out the circumstances under which you may be required to pay for those continued services.6

Managed care (MCO) appeals through Cardinal Care

Most Virginia Medicaid members get their care through Cardinal Care Managed Care (CCMC), the state's managed care program, run through DMAS. If a managed care organization (MCO) took the action you want to challenge, you have to work through the plan before you can reach a state fair hearing. These rules come from the federal managed care regulations at 42 CFR Part 438 Subpart F.

The five Cardinal Care plans

As of the Cardinal Care Managed Care contract that took effect July 1, 2025, the five participating plans are Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons of Virginia, Sentara Health Plans, and UnitedHealthcare of the Mid-Atlantic.2 Molina Healthcare left the program after June 30, 2025, and its members moved to Humana.2

What counts as a plan action

Your 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 service it previously approved, a denial of payment, or a failure to act within the required timeframes. That notice must tell you how to appeal and how to ask that your benefits continue.6

The internal appeal and exhaustion

You have 60 days from the date on the determination notice to request the plan's internal appeal.4 Each Cardinal Care plan has one level of internal appeal, and you must exhaust it before you can request a DMAS fair hearing.2 There is one exception. If the plan fails to meet the federal notice and timing rules, your appeal is deemed exhausted and you may request a state fair hearing without waiting for the plan.7

How fast the plan must decide

The plan must resolve a standard internal 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.7 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or your ability to regain function.

After the plan's decision

Once the plan issues its internal appeal decision, you have 120 days from receiving it to request a DMAS fair hearing.2 Federal law sets that state fair hearing window at no fewer than 90 and no more than 120 days, and Virginia uses the full 120.7

How to request a Virginia Medicaid fair hearing

File your Request for Appeal with the DMAS Appeals Division. Virginia accepts the request five ways:2

• Online through the AIMS appeals portal
• Email to appeals@dmas.virginia.gov
• Fax to (804) 452-5454
• Phone at (804) 371-8488
• Mail or in person to the Appeals Division, Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219

A member, or a legal or authorized representative acting with the member's written consent, may file the request.2 Whatever method you use, do it within the 30-day window, and if you want to keep your benefits, file before the effective date of the action. The DMAS Appeals Division provides the hearing, and its decision may be appealed to court for review of the record.2

Learn More

Find personalized help navigating a Virginia 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.