What to Do When Health Coverage is Denied
Perhaps you or a loved one has applied for Medicaid and the state Medicaid agency denied the application. You may be wondering what you can do in just such a situation, and if you are, then fear not; this article is for you. So, if you find yourself facing a denial of your application, you can appeal it, and while the state agency will handle the appeal, it has to follow the federal Medicaid appeal rules
The Denial Notice
If a Medicaid agency denies an application, it must do so with a written denial notice. States must also follow the federal deadlines when issuing these notices, and they have the following amounts of time to send you your denial notice:
- 90 days from the date of the application if you apply for Medicaid on the basis of a disability.
- 45 days from the date of application if you apply on some other basis.
You should get a written notice within those deadlines. The notice will also inform you of your right to have a hearing to appeal the denial, how to request the hearing, and that you also have the right to represent yourself, hire an attorney, or have a spokesperson (like a friend or relative) to help you. It must also provide reasons as to why your application was denied and include the specific rules that your state Medicaid agency is using to deny the eligibility.
The appeal deadline is often the most important piece of information on your appeal notice. You have to request the appeal within the deadline, or you’ll have to justify a late appeal. Every state has different deadlines, but all of them need to be no more than 90 days from the date the denial notice is mailed.
Preparing for the Hearing
Once the appeal is set for a hearing, you have to appear either in person or via phone, depending on state procedures, or risk your appeal being dismissed. If it is dismissed because you missed the hearing, you will need to prove “good cause” for missing the hearing to get it reopened, and this can be difficult to prove.
Your state Medicaid agency will also send you information telling how the hearing will be conducted. In a few states, the state agency conducts the hearings, while others have separate hearings agencies or use the court systems. Hearings have to be done at a reasonable time, date, and place, after adequate notice, and they can be conducted by one or more judges, as long as those people are impartial and weren’t directly involved in the original decision.
Prior to the hearing, federal Medicaid rules require the states to allow applicants to view their files and look over all documents the agency has relied on to deny the application. Be sure to write down points you want to make so you don’t forget them, and you have the right to have your own witnesses testify at the hearing and the right to ask any agency witness questions too. If something comes up during the hearing (like a medical question) that you think might be solved by getting more information to the judge, you can ask him or her o give you more time to get the information before making a decision.
You may also want to have an attorney represent you, and you can call your local legal aid office to find out if they help clients in Medicaid appeals, or contact a lawyer. Federal Medicaid rules also let you use a relative, friend, or other spokesperson you choose to help you with the appeal, or you can represent yourself.
So there you have it; a quick look at what you can do if you find yourself facing a Medicaid application denial.