If your Medicaid coverage in West Virginia 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., A West Virginia Medicaid appeal covers every denial, reduction, termination, and prior authorization refusal, and one deadline on your notice decides whether your coverage keeps flowing while you fight it.

In This Guide

What you can appeal in West Virginia Medicaid

Federal law guarantees every Medicaid applicant and beneficiary 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 West Virginia's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted upon promptly, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.

In West Virginia, the fair hearing is held by the Board of Review (BOR), the impartial hearing body inside the state Office of Inspector General (OIG) that hears cases for the Department of Health, the Department of Human Services (DoHS), and the Department of Health Facilities, including Medicaid eligibility and covered-service disputes.

In practice, you can appeal:

  • An application denial (income, assets, household composition, or citizenship and identity documentation)
  • A termination or reduction of your eligibility or covered services
  • A cut to your service hours, such as personal care or in-home support
  • A prior authorization denial or a level-of-care determination
  • A managed care plan's denial, reduction, suspension, or termination of a service
  • A renewal or recertification denial

The right reaches across the whole program. 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 cut or termination does not lose coverage just for appealing.

West Virginia Medicaid appeal deadlines that decide your case

Two deadlines govern a West Virginia Medicaid appeal, and they fall on different dates.

The request window runs up to 90 days. 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. West Virginia applies that federal maximum: you may request a fair hearing (or an optional Pre-Hearing Conference) within 90 days of the effective date of the action on your notice. Read the exact date off your own notice, and file well before it.

The continuation window closes earlier, before the effective date, and it is the one that keeps your benefits flowing. It is covered in the next section.

Managed care denials carry their own two windows, 60 days then 90 to 120 days. If your denial came from a managed care plan, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal. After the plan resolves that appeal against you, the state must 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; the exact number within that band is set by the state.

One more deadline protects renewals. If West Virginia terminated your coverage only because you did not return a renewal form or requested information on time, you do not always have to appeal or reapply: under 42 CFR 435.916, if you submit the renewal form or the missing information within 90 days after the termination date, the agency must reconsider your eligibility without a new application.

How to keep your benefits during a West Virginia Medicaid appeal

Keeping your benefits during the appeal is called aid paid pending. It is not automatic: you have to request it, and you have to request it before the effective date on your notice.

In West Virginia, if you ask for a Pre-Hearing Conference or a Fair Hearing because of a decrease or closure of your benefits, and you ask before the effective date of the proposed reduction or closure, your benefits are not reduced or stopped while a final decision is pending. If you wait until after the effective date, the change takes effect, and you may still request a hearing within 90 days, but your benefits will already have changed.

The federal rule behind this sits at 42 CFR 431.230(a): when the agency sends the required advance notice and you request the hearing before the date of action, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless the only issue is one of federal or state law or policy. The trigger is the effective date on your notice, not a flat count of days.

Continuation does not apply to every case. West Virginia does not continue benefits during an appeal of a Supplemental Nutrition Assistance Program (SNAP) mass change, an annual cost-of-living increase, or a change where you waived advance notice.

There is one cost to continued benefits. If your benefits continue and the state's action is later upheld, the agency may recoup the cost of the services furnished during the appeal. That risk is a reason to keep good records and to move quickly, not a reason to skip the appeal.

The practical takeaway: when any adverse-action notice arrives, find the effective date on it, request the hearing before that date, and put your request to continue benefits in writing.

Managed care (MCO) appeals: exhaust your plan first

Most West Virginia Medicaid members get their care through Mountain Health Trust, the state's managed care program, which covers roughly 87% of Medicaid membership through four contracted Managed Care Organizations (MCOs): Aetna Better Health of West Virginia, The Health Plan of West Virginia, Highmark Health Options of West Virginia, and Wellpoint of West Virginia. 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.

Some services sit outside managed care. West Virginia carves long-term care, Home and Community-Based waiver services, point-of-sale pharmacy, and non-emergency medical transportation out of Mountain Health Trust. A decision about one of those services is appealed directly to the Board of Review, because there is no plan-level appeal to exhaust first.

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 tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue during the appeal.

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. The plan has only one level of appeal, and you must exhaust it before requesting a state fair hearing; the state fair hearing is not available until the plan appeal is exhausted. If the plan fails to meet the notice and timing rules, the appeal is deemed exhausted and you may go straight to a state fair hearing.

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. Request the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

After the plan upholds its denial, you have 90 to 120 days, set by the state, to request a state fair hearing from the Board of Review.

How to request a West Virginia Medicaid fair hearing

Filing with the right office is what starts the clock. In West Virginia, a fair hearing is requested from the Board of Review (BOR), the impartial hearing body within the Office of Inspector General (OIG). You can request a hearing verbally or in writing, using any of these methods:

An eligibility appeal may also be directed to your local Department of Human Services (DoHS) office. Before the formal hearing, the Board offers an optional informal Pre-Hearing Conference, a chance to resolve the dispute without a full hearing. Whatever method you use, request the hearing before the effective date on your notice if you want your benefits to continue, and keep a copy of everything you send.

Frequently Asked Questions

How long do I have to appeal a West Virginia Medicaid denial?

It depends on the decision. An eligibility or covered-service decision runs on the 90-day request window., A managed care denial runs on a different clock: 60 calendar days to file the plan's internal appeal first, then a separate state-set window to reach a fair hearing. And a renewal termination has its own path: if you turn in the missing renewal information within 90 days of the termination date, federal law requires the agency to reconsider your eligibility without a new application, even if you never file an appeal.

Can I keep my Medicaid benefits while I appeal?

Yes, if you request the hearing before the effective date of the action on your notice and ask that your benefits continue. West Virginia does not reduce or stop your benefits, pending a final decision, when you file before that date. If you win, there is no interruption; if you lose, the agency may recoup the cost of the services it continued during the appeal.

Do I need a lawyer for a West Virginia Medicaid fair hearing?

No. You can represent yourself, bring a family member, or authorize someone else to act for you, and the Board of Review offers an informal Pre-Hearing Conference before the formal hearing. Representation still helps for level-of-care, personal care, and complex prior authorization disputes, where the decision usually 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 plan, and it is the required first step for a managed care denial. 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 from the Board of Review, and you then have 90 to 120 days, set by the state, to request it. A fee-for-service decision, or one about a service carved out of managed care, skips the plan step and goes straight to the Board of Review.

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. MedicaidWest Virginia Medicaid: The Complete GuideWest Virginia Medicaid covers long-term care via BMS with a medically needy spend-down, no Miller Trust, a $2,000 asset limit, and $50 PNA. Apply on WV PATH. MedicaidWest Virginia Medicaid Eligibility and Income LimitsWest Virginia Medicaid has two income limits: $2,982/month with a $2,000 asset cap for long-term care, and 138% FPL with no asset test for adults under 65. MedicaidHow to Apply for West Virginia MedicaidHow to apply for West Virginia Medicaid via WV PATH online, phone, or in person, plus the documents, the spend-down, spousal rules, timelines, and appeals.

Find personalized help navigating a West 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.

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