Wisconsin Medicaid Appeals and Fair Hearings

If your Medicaid was denied, cut, or terminated in Wisconsin, you have the right to appeal and request a fair hearing, and you can often keep your benefits during the appeal.1 The deadline that governs your hearing request in Wisconsin is 45 days from the effective date printed on your notice, and a separate, earlier deadline decides whether your coverage keeps flowing while you fight it.2

In This Guide

• What you can appeal in Wisconsin Medicaid
• The Wisconsin Medicaid appeal deadlines that decide your case
• How to keep your benefits during a Wisconsin Medicaid appeal
• Managed care (MCO) appeals: appeal your plan first
• How to request a Wisconsin Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in Wisconsin Medicaid

Federal law guarantees every Medicaid applicant and member the right to a fair hearing before the state. Under 42 CFR 431.220, the state must grant a hearing to anyone whose claim for medical assistance is denied or not acted on with reasonable promptness, and to anyone who believes the agency acted erroneously against them.1 In Wisconsin, that hearing is conducted by the Wisconsin Department of Administration, Division of Hearings and Appeals (DHA), a body separate from the Wisconsin Department of Health Services (DHS), which administers Medicaid.2

That right reaches across the whole program. You can appeal:

• An application denial, whether for income, assets, or documentation
• A termination or reduction of your eligibility or covered services
• A reduction in service hours, such as personal care or supportive home care
• A prior authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service

Any adverse action on your Medicaid can be challenged. What changes from case to case is the deadline and, for managed care members, whether you appeal your plan first.

The Wisconsin Medicaid appeal deadlines that decide your case

Two windows matter in Wisconsin, and they are not the same number. The request window sets how long you have to ask for a hearing; the continuation window sets whether your coverage keeps flowing while you wait.

DHA has authority to conduct a Medicaid hearing only if it receives your written request within 45 days of the action's effective date.2 Federal law under 42 CFR 431.221(d) allows a reasonable time not to exceed 90 days from the date the notice is mailed, so 90 days is the federal ceiling and Wisconsin's 45 days is the operational window that governs you.3 Read the effective date off your own notice and count from there.

For managed care denials, a different set of federal timeframes applies to your plan appeal first. You have 60 calendar days from the date on the plan's adverse benefit determination notice to file the internal appeal.6 The window to reach DHA afterward is set from the plan's resolution notice.5

One more deadline protects renewals. Under 42 CFR 435.916(a)(3)(iii), if your coverage ended only because you did not return the renewal form (a procedural termination, not an eligibility-based one), DHS must reconsider your eligibility on the basis of that late-returned form if you submit it within 90 days after the termination date, without requiring 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, Wisconsin may offer the same window but is not required to, so ask DHS.7

Use this table to match your situation to its clock:2,3,6,5,7

How to keep your benefits during a Wisconsin Medicaid appeal

Your benefits do not continue automatically because you appealed. Continuation turns on when you file.

Under the Wisconsin rule, DHA may order your Medicaid benefits to continue unchanged while a decision on the hearing is pending.2 The trigger is timing: DHA can reverse that continuance order only when the hearing was not requested before the action's effective date, so requesting the hearing before your benefits change is what preserves them.2

This tracks the federal continuation rule at 42 CFR 431.230. If the agency sent the required advance notice and you request the hearing before the date of the action, it 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.4

If you miss that date only narrowly, a separate federal provision may still help. Under 42 CFR 431.231, the agency may reinstate services when the hearing is requested no more than 10 days after the date of the action. That provision permits reinstatement rather than guaranteeing it, so ask in writing right away and do not treat it as a second deadline you can rely on.4

There is one cost to weigh. If your benefits continue and the agency's action is later upheld, Wisconsin may recover the cost of the benefits that were continued solely under this provision.2 The federal rule permits the same recoupment.4

Continuation is not automatic: find the effective date on your notice and request the hearing in writing before it.

Managed care (MCO) appeals: appeal your plan first

Wisconsin delivers most of its long-term-care Medicaid through managed care: Family Care, Family Care Partnership, and PACE.2 If your care comes through one of these programs, you appeal your plan before you can reach a state fair hearing.

A member who gets a notice terminating, denying, or reducing services must first file an appeal with their MCO's grievance and appeal committee, before asking DHA for a state fair hearing.2 You start that appeal by contacting your care manager or your MCO's member rights specialist, or by submitting the Appeal Request form for MCOs (F-00237). At the committee you may appear in person, bring support such as a family member or witness, and give evidence.2

The participating Family Care, Partnership, and PACE MCOs for 2026 are Anthem; Community Care, Inc.; iCare and Inclusa; Lakeland Care, Inc.; and My Choice Wisconsin, Inc.2

Under 42 CFR 438.404, the plan must give you timely and adequate written notice of an adverse benefit determination, meaning the notice that tells you a service is being denied, reduced, suspended, or terminated. That notice must state the determination and the reasons for it, explain your right to appeal and how to exhaust the plan's single level of appeal and then request a state fair hearing, and tell you that you can have benefits continue while the appeal is pending and how to ask for that.8

If the plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving your appeal, you are deemed to have exhausted its appeal process and may go straight to a state fair hearing rather than waiting on the plan.5 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.6

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.5 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or ability to function.

After the plan upholds its denial, you request the state fair hearing from DHA. Federal law requires the state to give you no less than 90 and no more than 120 calendar days from the date of the plan's notice of resolution, and each state sets its exact deadline inside that band.5 The plan's resolution notice has to explain how to request the state fair hearing, so follow the procedure it gives you and file well inside 90 days.8

How to request a Wisconsin Medicaid fair hearing

For a Wisconsin Medicaid fair hearing, you file in writing with the Division of Hearings and Appeals. There are two ways to make the request:

• Complete the Request for a Fair Hearing form (DHS-28), or
• Write and send a letter that asks for a hearing.

Send either one to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707-7875. You can also fax it to 608-264-9885 or email it to DHAMail@wisconsin.gov.2 DHA schedules the hearing once it receives your request, so keep proof of the date you sent it.

An Administrative Law Judge (ALJ) conducts the hearing and issues the decision.2 If you disagree with the outcome, you have two further options: request a rehearing by DHA within 20 days of the decision, and appeal to the Circuit Court of the county where you live within 30 days of the decision or the rehearing denial, whichever is later.2

Learn More

Find personalized help navigating a Wisconsin 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.