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 meeting a separate, earlier deadline is the surest way to keep your coverage 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 gives Medicaid applicants and members 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:1

• 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
• A nursing facility's decision that you must be transferred or discharged

Nearly any adverse action on your Medicaid can be challenged. The narrow exception is a change that flows automatically from a federal or state law: the state need not grant a hearing when that law is the only issue,1 and DHA may dismiss a request about a law or policy change affecting many members unless you question how it applies to your own case.2 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 is how you keep your coverage 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. If you are dually eligible and enrolled in an applicable integrated plan, plan-level appeals follow separate federal rules (42 CFR 422.629 through 422.634) instead, so check the deadline on your plan's notice.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 or requested information (a procedural termination, not an eligibility-based one), DHS must reconsider your eligibility in a timely manner, without requiring a new application, if you submit the renewal form within 90 days after the termination date. Ninety days is the federal minimum; 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, 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:2,3,6,5,7,4

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 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.4

If you miss that date, two federal provisions may still help. Under 42 CFR 431.231, the agency may reinstate services when you request the hearing no more than 10 days after the date of the action, and services it reinstates then continue until the hearing decision unless the hearing finds the only issue is one of federal or state law or policy. If the agency acted without sending the required advance notice, reinstatement is not optional: it must reinstate your services and continue them until the hearing decision if you request a hearing within 10 days of receiving the notice (receipt is counted as 5 days after the date on the notice unless you show it arrived later) and the action did not result from applying federal or state law or policy. Outside that case reinstatement is the agency's choice, so ask in writing right away.4

There is one cost to weigh. If your benefits continue and the agency's action is later upheld, the state may recover the cost of benefits furnished solely because of the continuation. That is why you may waive continued benefits, and the IM agency must tell you that you can.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). DHS suggests talking to your care manager first to try to resolve it informally. At the committee you may appear in person, bring support, and give evidence.2

As of the DHS MCO contact list dated June 2026, the participating Family Care, Partnership, and PACE MCOs 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 notice in writing 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; tell you that you can get free copies of the documents and medical-necessity criteria behind it; explain your right to request an appeal, including exhausting the plan's single level of appeal, and your right to request a state fair hearing, and the procedures for both; say when an appeal can be expedited and how to ask; and tell you that you can have benefits continue while the appeal is pending, how to ask for that, and when you might have to pay for those services.8

If the plan fails to adhere to 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 your appeal as quickly as your health condition requires, and no later than the state's deadline, which federal law caps at 30 calendar days for a standard appeal and 72 hours for an expedited appeal from the day the plan receives it. Those deadlines can run up to 14 calendar days longer if you ask for the extra time, or if the plan shows the state it needs additional information and how the delay is in your interest. If the plan takes an extension you did not ask for, 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.5 If waiting could harm your health, ask for the expedited track; the plan's denial notice must explain when an appeal can be expedited and how to request it.8

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.5 If your benefits continued during the plan appeal and you want them to keep going, the deadline is much shorter: continued benefits end unless you request the state fair hearing and continuation within 10 calendar days after the plan sends its adverse resolution notice. If you take the full window to file, you keep the appeal but can lose coverage in the meantime.5

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 Because DHA must receive your request within 45 days, send it early and keep proof of when you sent it. You may first ask your IM agency for an informal conference; that is your choice, it neither delays nor replaces a fair hearing, and you can request a hearing without contacting the agency first.2

An Administrative Law Judge (ALJ) conducts the hearing, and DHA must issue its decision, and the IM agency carry it out, within 90 days of the date DHA receives your request. In some cases the ALJ issues a proposed decision instead; any party may send DHA written comments within 15 days of receiving it, and the Secretary of the Department of Health Services then makes the final decision.2 If you disagree with the final decision, you have two further options. You can request a rehearing by DHA within 20 days of the decision; DHA may grant or refuse it, holds one only for an error of law, an error of important fact, or new evidence you could not have presented at the first hearing, and a request it does not act on within 30 days is deemed denied. You can also appeal to the Circuit Court of the county where you live within 30 days of the decision or the rehearing denial, whichever is later, and a rehearing is not required first.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.