What To Do When Medicaid Denies You Coverage

Man reviewing Medicaid appeal form

Most people who get long-term care rely on Medicaid to pay for it. So, it can be a big deal if the state decides you are not eligible for Medicaid, or cuts down on the amount of care you can get.

Luckily, you can appeal that decision. By law, the state has to give you a chance to appeal any decision about your care that impacts your benefits. If you win, you get your benefits back, and Medicaid will have to pay for any care you received during the appeal.

But the process can be complicated. Find out what you need to know about the Medicaid appeals process, and what you should do to give yourself the best chance of winning.

Consider Talking to a Lawyer about Your Medicaid Appeal

This guide will explain the basics of the appeal process. But, if you are having trouble applying for Medicaid or getting the services you need, you may want to talk to a lawyer.

Community Legal Services of Pennsylvania may be able to help. They offer free legal advice for low-income Philadelphians. That includes seniors who are having problems with Medicaid.

The Pennsylvania Legal Aid Network is also a great resource if you live outside Philadelphia.

Common Reasons Medicaid Will Deny You Coverage

Under the law, you can appeal if Medicaid denies you coverage, or if they stop providing you with a certain service.

You cannot appeal changes to the law, only facts about your care. So, you could not appeal if the government decides Medicaid will no longer cover a home health aide for anyone. But, if Medicaid decides you specifically do not qualify for a home health aide, you could appeal that.

Generally, Medicaid will deny you coverage for one of two reasons. Either it will be about your financial situation, or over your health needs. Either way, the appeals process will be the same. The only thing that will change is the evidence you might need to gather.

Your Finances

The state decides who is eligible for Medicaid based on your income and assets. In Pennsylvania, the monthly income limit is 300% of the monthly federal Social Security benefit. For 2022, that is $2,523 gross a month.  

You can see more about the eligibility requirements on our guide to getting coverage under Medicaid. If you are over the income limits—or if Medicaid thinks you are—they will deny you coverage.

The other financial reason they can deny you coverage is if you gave away too much of your property in order to fall below the asset limits. The state will check the last five years of your bank records to see if you have given away your property without getting paid for it. If they find out that you have, or if you don’t submit five years of bank records, they can deny you coverage.

Medical Reasons

The state will also check to see how much medical care you need. For long-term care and other in-home services, you must need the same level of care as a nursing home. If you don’t need that level of help, you may not qualify for in-home care.

Sometimes, you may qualify for Medicaid, but you might not get as many hours as you feel like you need. Generally, that’s because someone assumes your family is providing more care for you than they actually are.

Remember, federal law requires that all care from a family member or friend must be voluntary. Your loved one decides how much care they can provide. Then, the total hours that Medicaid covers will be based on that. No one is allowed to decide how much care a family member “should” be providing for you.

Speak Up for Yourself

If Medicaid denies you coverage for any of these reasons, you have the right to an appeal. And it’s important that you use it. You can also request a quicker appeal if your health is in jeopardy because of lower services.

Medicaid programs often make mistakes. The appeal process is your way to fix them. If the state made a mistake, an appeals worker may change their decision immediately.

If the appeal does get to a hearing, Medicaid has to give you your benefits if you win. And, you can even get care you need during the appeals process (more on that below).

If a managed care organization (MCO) handles your coverage, you can follow up with them first using their internal process. If that appeal fails, then you might have to request a state hearing after that. But either way, the process will be mostly the same.

The State Must Give You Notice

State programs and MCOs must send you a notice if they deny you benefits or reduce your benefits.

Generally, this notice has to be mailed 10 days before they take any action (but the rules for MCOs are a bit more flexible). The notice has to include:

  • What they are going to do
  • Why they are doing it
  • The laws that support their decision
  • An explanation of the appeals process

It’s important to note that you do not have to wait until you receive a notice before you can request an appeal. You can request one at any time. But, if you wait until you receive a notice, you have between 20 and 90 days (it varies by state) after that to file your request.

In Pennsylvania you have to request a hearing in writing. You can see an example of an appeal request form here. A form like this one will be at the end of your notice.

Getting Benefits During the Appeal

If you can, you want to request an appeal hearing before the program’s decision is set to take effect. That way you can keep your benefits during the appeal.

So, if Medicaid says you will stop receiving care on March 21, you want to request an appeal on March 20 or earlier. Then, your benefits will stay at the previous level until the hearing is finished. This is called “aid paid pending.” The aid is paid pending the result of your appeal.

If you lose your appeal, technically the state could ask you to pay for the care you received during the appeal. BUT states rarely make these requests. They know it would be hard for Medicaid recipients to pay back that money.

Preparing for Your Medicaid Appeal Hearing

Once you have requested a hearing, the state will work to schedule it for a convenient time and place. You can do it at the Medicaid office, at your own home, or over the phone. In Pennsylvania, most hearings are done over the phone.

An impartial person who was not involved in the original decision will conduct the hearing.

You’ll want to make sure you are prepared for your hearing. Follow the steps below to give yourself the best chance.

Review All the Relevant Documents

By law, you have the right to review your case file and any documents the Medicaid program may use at the hearing.

Often, you might see that the files do not include important information. This may be the reason the state ruled against you. Then, all you need to do is submit this information to win your case.

Even if that’s not the problem, reviewing these files will give you a better idea of why you have been denied benefits—and what you need to prove to get them back.

You’ll also want to write a summary of the facts and the laws that show you deserve benefits. This is where speaking to a lawyer may be helpful. You can then submit this summary before the hearing to save the judge time and effort.

Talk to Witnesses Ahead of Time

During your hearing, you have the right to present witnesses. These witnesses will help you argue for yourself, and against the other side.

Your witnesses can include family members, care providers, doctors, bank officials, or anyone else you think can help your case. They can testify in-person or on the phone.

The state must do certain things to make it easier for you and your witnesses to testify:

  • Provide a translator for anyone who does not speak English
  • Provide transportation for you and your witnesses to and from the hearing
  • Pay for any medical tests that they think are necessary

Once you decide on your witnesses, you want to meet with them ahead of time to discuss your case. Let them know what to talk about and what the process is like. Then, they will know what to expect at the hearing.

Decide Who Will Be with You

During your hearing, you can pick someone to represent you. That can be a friend, family member, or a lawyer. This person can attend the hearing with you and speak on your behalf.

Remember, you can hold your hearing in person or over the phone. So, this person does not need to be there with you. You can call them instead.

Show Up!

It’s crucial that you show up (or call in) for your hearing. If you don’t show up, your case can be dismissed immediately.

If that happens, you’ll need to show “good cause,” in other words provide a good reason, before the case can be reopened. Showing good cause is hard. Forgetting the date or losing the notice is not good enough.

Plus, missing your hearing will impact your credibility with the judge. So show up!

The Decision

The judge will usually issue a ruling on your hearing within 90 days. They can delay the ruling by up to 30 days if you request more time, or if a medical exam cannot be completed in time.

The judge can only consider evidence presented during the hearing, also known as the hearing record, when making their decision. That record includes testimony from the hearing, and any documents or evidence you submit. If you want the judge to consider some piece of evidence, you need to submit it.

The state must accept any ruling the judge makes in your favor. So, if the judge decides you deserve benefits, Medicaid must give you those benefits.

If the judge rules against you, then you are entitled to another appeal to state court.

Know Your Rights

Good Medicaid coverage is vital for most people who need long-term care, especially people who need a home caregiver. If you know your rights, you can make sure you get the care you need and deserve. Remember, you need to be your own advocate. You have the right to a Medicaid appeal, so use it.

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Penn Asian Senior Services