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If your claim for Medicaid is denied, you have the right to appeal that decision.

The appeals process is very similar to the Social Security appeals, since they are part of the same legislation. However, each state handles its own appeals process. As part of the denial process, the state in which you live will tell you the procedure for making an appeal.

The purpose of the appeal is the same for each state even if the procedures are different: you want to provide Medicaid with enough new information or explain old information so that they will be justified in reversing their denial and granting you benefits.

In order to successfully change an approval into a denial, you need to know:

  • The reason for the denial.
    • The reason for the denial should be spelled out in the letter of denial, but don't hesitate to contact the person with whom you've been working or who signed the letter if the reason is not clear. Try to find out precisely the reason for the denial - not that it was just "financial" or "medical." For example:
      • If the reason is financial (such as the Analyst thought your assets were too high for Medicaid eligibility), you need to know how high and how the number was arrived at before filing an appeal arguing about your income level. For more information about denials for financial reasons, click here.
      • If the reason is medical, that is they don't think you are disabled, find out which medical records were used to make that determination. Again, this should be in the denial letter, but you may have to contact the Analyst to find out. For more information abou denials for medical reasons, click here.
  • Your rights of appeal.
    • Medicaid appeals are in two levels: Reconsideration is the first level of appeal. If you continue to be denied, you can then appeal to an Administrative Law Judge. If those levels do not provide the result you seek, you can take the case to state court. 
    • For information, see: Reconsideration and Administrative Law Judge. 

If not before, it is preferable to have an attorney do the appeal to an Administrative Law Judge.

For more information, see:

NOTE: In most states there are programs that will provide information about eligiblity, applying for, appeals, and living with Medicaid. There are even programs which supply people to attend hearings with you. Health insurance assistance program primiarily deal with Medicare, but they also deal with some aspects of Medicaid. You can locate a health insurance assistance program at: see: offsite linkIf the agency doesn't have your answer, it can point you to an agency that does. You can also contact a legal expert to learn about special rules that may help in your situation. If the person charges for his or her services, the more homework you do before meeting, the less expensive your legal feels are likely to be.

Reason for Denial: Not Eligible Financially

You may be denied Medicaid because it is claimed that your resources and/or your income is/are too high to qualify. In these cases, an appeal is pretty cut and dry. It's an argument over numbers. If you can prove your numbers are right, you'll win. If not, Medicaid's numbers will win.

When looking for evidence to support your position, remember that in the absence of some pretty convincing proof, Medicaid's numbers are presumed to be correct.

NOTE: In states that cover people who are "Medically Needy," a mistake may not deny you eligibility for Medicaid, but it can inflate the amount you must pay out of your pocket for health care.

The most common reason for denial of Medicaid due to financial ineligibility is a misunderstanding of what is income and what are resources. Perhaps the way you reported something caused Medicaid to mistakenly call it income or resources when it was not. This could happen in several areas:

  • Free Rent: Sometimes benefits are denied because Medicaid claims that because you live rent-free, the value of your rent should be included in your income making your total income exceed the Medicaid minimum.

You will need proof that you are not living rent-free. For example, you can provide a written agreement that you are being loaned the money each month from the property's owner. If there is a loan, you must show the facts of a loan: the amount you are being loaned, a rate of interest and date on which the loan will be repaid.

It could be that you are loaned the rent each month and that the loan plus interest will be paid from the death benefit of the life insurance policy that is described in the agreement. (You can still obtain life insurance. See How to Obtain Life Insurance.)

  • Other in-kind or gift assistance: Many people think that unless they are given cash, it doesn't count as income. If you are denied Medicaid for this reason, review Supplemental Security Income to see if your gifts may be exempt.

Reason for Denial: Not Eligible Medically

A denial due to not meeting Medicaid's standard for being totally disabled is the most common reason a claim is denied, but it can offer many opportunities for getting the denial reversed.

Disputing a claim by Medicaid that you are not disabled is going to take time, research and preparation. Whether or not, and exactly when, you were disabled enough to qualify for benefits is a very subjective issue despite Medicaid's attempts to make it objective. Your goal will be to use records that they haven't seen, and reinterpreting records they already have, to prove your point.

  • Check to see what medical records Medicaid used as a basis for their denying that your condition is severe enough to qualify for benefits.
  • The denial letter should list each doctor whose records the analyst used.
  • Check the list against your list of doctors you informed Medicaid about.
  • Get copies of the medical records each doctor filed, plus copies of any medical records that were not filed or were filed but which were not listed by Medicaid. Your objective is to find medical records that Medicaid has not seen.
  • Note that all of your medical problems do not have to come from the same condition. For example, if you are dealing with a physical disease, also consider submitting records from your therapist treating you for depression.
  • If the question is the onset date of your disability, go through the medical records to show that you had the same symptoms at the earlier time as you did at the time Medicaid used to declare you disabled.

When appealing denials of treatment or of treatment procedures, your physician's assistance is vital.

The First Level of Appeal: Reconsideration

Generally, you have sixty days from the letter of denial to restate your case in writing to Medicaid.

Reconsideration is exactly what it says: it is a request that Medicaid reconsider the denial of your claim and, hopefully, reverse their position and approve the claim.

To get Medicaid to change an opinion, you must give Medicaid something that provides a reason to make a change. Unless you can explain information Medicaid already has in a new light, or provide information Medicaid doesn't already have, the denial is not likely to be reversed.

  • To start the appeals process, you must follow the appeals instructions that are included in your denial letter.
    • Forms to request a Reconsideration of your claim will probably accompany the denial letter.
    • If not, you may get them from where you first applied for Medicaid.
  • If you had extensive medical problems between the initial application and the Reconsideration:
    • While the records of your newer situation will certainly help gain an approval that you are now disabled, Medicaid may establish an onset date that is much later than the one for which you originally applied.
    • If it is your goal to both get approved for Medicaid and have the onset back when you first applied, include more records from the earlier period so Medicaid will be able to see that your disability goes back that far.
  • Submit a letter from your doctor.
    • Show your doctor the denial letter and review the medical records together after you've had a chance to review them.
    • Point out where you think the documentation of your symptoms is weak, and point out items you may have reported to your doctor that didn't make it into the record. Ask your doctor to write a letter identifying from a medical point of view his or her opinion of your ability to work and exactly what keeps you from working.
  • Submit third party testimony.
    • Especially if you didn't submit any with your initial application, obtain letters from people you work with as well as people you live with or to whom you are close.
    • Ask them to write their observations of any changes in you. Ask them to be specific and to pinpoint dates as much as they recall. For samples, see Social Security Disability Insurance (SSDI).
  • Submit other evidence.
    • A great source of other supporting evidence can be work or school records which sometimes contain a wealth of information about job performance and psychological testing.
    • Any records that were generated before applying for Medicaid benefits will be given greater weight than those which are generated afterward.
  • Take your time completing the form: Request For Reconsideration. This form along with any documentation you submit with it becomes your appeal, so it is important that you complete it carefully and thoroughly.

When you review the form you will see that most of such requests are pretty self-explanatory, even though they vary from state to state.

Generally, the heart of the form and the key to your success in overturning a denial is the section that says something to the effect that: "I do not agree with the determination made on the above claim and request reconsideration. My reasons are:"

Here is where you want to present your argument and the facts that support it. See the particular section above that applies to you for advice on what should be completed.

List every argument that is in your favor. If you have one strong reason and two weaker ones, list them all even if you're convinced the strong argument alone will get your claim approved. Some claims examiners and Administrative Law Judges will not allow you to present any new evidence that isn't in your request for appeal so you want to include everything you can think of. Also bear in mind that while one argument may be persuasive to you, it may be another argument that is persuasive to the person who will review your case.

Administrative Law Judge

An Administrative Law Judge is the second appeal level. Once Reconsideration has refused to reverse the initial denial, you can file to have your claim reviewed by an Administrative Law Judge. That is the term that Social Security uses for its second level appeals and chances are your state uses the same term or something similar.

This level is a hearing, like an informal trial, before a judge. You, or your representative, presents your case, Medicaid presents its case, and the judge decides whether to approve your claim or not.

Generally, you must request the Administrative Law Judge hearing within sixty days of having your Reconsideration denied.

The Overview

The denial letter after Reconsideration will describe the procedure and include a form in which to request a hearing before an Administrative Law Judge. Again, Medicaid allows your 60 days plus 5 days for mailing time from the date of the denial to submit your request for an Administrative Law Judicial Hearing.

This is the stage where you may want to consider enlisting legal assistance. Most people who appear before an Administrative Law Judge win their case, so it is in your best interest to present the best case possible and an attorney or other trained professional is likely to be needed to accomplish that.

The form requesting a hearing before an Administrative Law Judge will vary from state to state, but all will ask the same basic questions about the claim. There are some things to keep in mind as you complete the form:

  • Like the Request for Reconsideration, you need to do some planning about just how you intend to present your arguments at the Administrative Law Judge before you complete the Request form.
  • If you plan to use an attorney, find the attorney and let him or her assist you with the form. The attorney will be able to help you clarify the issues. Also, more paperwork is required if you send in this form without an attorney and engage one later.
  • The request for an Administrative Law Judge Hearing will ask: "I REQUEST A HEARING BEFORE AN ADMINISTRATIVE LAW JUDGE. I disagree with the determination made on my claim because…:" or a similar question. This is where you outline your reasons why you think your claim should be approved. Write on a separate sheet of paper if needed. Again, it is important to include all the arguments you can think of that help prove your case. Some Administrative Law Judges do not permit you to raise any argument at the hearing that is not in your application for a hearing.
  • You will often be asked what new evidence you intend to provide. The more new evidence you can present, the more likely you are to win your appeal. New evidence may be in the form of medical records, third party testimony, or written statements by doctors, therapists and other health care providers.
  • If the form gives you a choice of whether or not to attend the hearing, experts advise that you should say "Yes." It is important that you attend the hearing and participate as much as possible -with your attorney's advice, if you use one.

NOTE: The steps listed below may vary slightly by state, but there will usually be something similar.

You will receive a confirmation letter from the Medicaid Office of Hearings and Appeals.

  • The letter will give you the date and time of your hearing as well as the address and phone number of the office where the hearing will be held.
  • By law, this letter must reach you at least 20 days before the date set for the hearing.

If you intend to represent yourself, immediately call the telephone number noted on the denial letter and ask for a copy of your file.

  • The file will show you what information they used to deny your claim and should help you determine what you need to provide to win approval.

Although these hearings are conducted in a manner similar to a court trial, they are much more informal. If you choose to represent yourself, you can do fine if you have adequate preparation and don't lose your cool.

  • The hearings are fairly informal. The only people likely to be there are the judge, a secretary operating a tape recorder for transcribing the proceedings, you (the claimant), your attorney if you have one, and anyone else you have brought to testify. In some cases, the Administrative Law Judge will have a medical doctor or vocational expert present to testify at the hearing. These people are supposed to give their objective opinion, but are more than likely to side with Medicaid's denial.
  • There is no jury or any spectators at the hearing.
  • There is no attorney at the hearing representing Medicaid trying to get the judge to deny the disability claim.

The Hearing: Preparation

Be prepared for the kind of tough, skeptical questioning that a judge might ask. For example, in a disability case:

  • The judge will often ask about education, work history, work activity, daily activities, medications taken, doctors visited, treatment received, symptoms of impairments, and whether a claimant thinks she can do something.
  • There may be a vocational expert at the hearing. "Just in case," think about the various jobs you may arguably be able to do, and be ready to explain why you could not do each of them. For instance, if you are visually impaired but not legally blind, you will have to show the presence of other disabling conditions. Explain how when the two are coupled together, they prevent you from doing the work.
  • In case Medicaid calls a doctor, become thoroughly familiar with all the medical records that Medicaid has reviewed. Be ready to point out the portions of the records that support your claim of disability.
  • Ask the Judge's clerk whether there will be a doctor or other expert attending. If so, find out as much information as you can about who the person is, and his or her expertise.

Go over your answers and practice saying them in front of a mirror so you can convey what you want the judge to know.

Be aware that the judge is likely to look at your physical demeanor when you enter and leave the room. He or she will also be trying to assess whether you are telling the truth when you make your statements.

Keep in mind that if you testify, if you have problems understanding the questions, don't hesitate to explain that to the judge.

The Hearing

For the hearing, you will go to the Office of Hearings and Appeals. Let the receptionist know you are there. Assume your hearing will start on time.

If possible, ask the clerk how long your particular Administrative Law Judge likes the hearing to last. You will usually be given between 30 to 60 minutes. You should watch the clock to be sure that you get your most important evidence testified to within the customary time. If your Administrative Law Judge likes his or her hearings completed in 30 minutes and you are at the 45-minute mark, you should be bringing up critically important information that has not already been testified about.

When you are called into the hearing room, the judge might already be there. Typically, the judge sits at the head of a long table with a court reporter to his right. You usually will sit facing the judge with the person transcribing the proceedings and any other people seated near by.

There are usually microphones in front of all of the key participants.

  • You may ask to be allowed to make an opening statement or argument. This can be a good way to focus the Administrative Law Judge's attention, but keep it brief -- only one or two minutes.
  • The etiquette differs from judge to judge, but you're on safe ground if you conduct yourself as you would in a regular courtroom. Address the judge as "Your Honor" and stand, or offer to, if you are able, when speaking unless told otherwise. Most Administrative Law Judges have their clerk tell you to stay seated when they rise, but some judges like to be accorded all of the formalities of a regular courtroom.
  • The Judge typically starts out by asking you or your lawyer if you object to any of the agency exhibits (which is the information in the file) and the basis for your objections.
  • If there are vocational experts or doctors present, it tends to make the hearing a little more formal and a little more like that of a traditional courtroom. However, in general, the Administrative Law Judge hearing is more like an informal fact finding conference. The critical issues are the witnesses' credibility, and, if the question is about disability, how the medical conditions impact the particular individual.
  • The styles of judging can differ greatly. Some judges question you themselves, and only allow the attorney to question you after they have finished. Some let the attorney question you and interrupt from time to time to ask relevant questions.
  • Typically, the judges have reviewed the files or been briefed by the clerks, and probably have a tentative ruling in mind before the hearing starts based on the exhibits in the file. That doesn't mean they aren't open to being persuaded at the hearing.
  • Some judges issue a tentative oral ruling at the conclusion of the hearing; but more often, they say nothing at the end except "thank you." Occasionally, a doctor or vocational expert will attend the hearings to give their impression of your ability to work based on your medical record and exhibits. They are both contracted by Medicaid to offer testimony, the physician on your medical record, the vocational expert on your ability to work. If possible, see if you can find out in advance of the hearing whether one or both will attend. If so, plan to cross-examine them.

Unfortunately, Medicaid does not impose a time limit on administrative law judges rendering their opinions. Allow four to six weeks to pass after the hearing, then follow-up with the hearing office on progress of the written opinion. When the judge is finished, you will receive his or her opinion by mail.