You spent weeks gathering bank statements and filling out forms for your mother's Medicaid application. Then the letter arrives: denied. Maybe it says she has too many assets, or that a document was never received, or it gives a reason you don't understand at all. It's tempting to give up or start over. Often the better move is to appeal.
This guide explains the federal fair hearing rules in 42 CFR Part 431, Subpart E, which every state Medicaid program must follow. States run their own hearing offices, so forms and names differ. This is general information, not legal advice.
Your right to a fair hearing
Federal rules require each state Medicaid agency to give applicants and beneficiaries a chance for a hearing when an application is denied or not acted on promptly, or when the agency ends, suspends or reduces benefits1. The agency has to tell people about this right in writing at the time of any action affecting their claim, including how to request a hearing6.
The agency also can't limit or interfere with a person's freedom to ask for a hearing, and it may help with the request2. A hearing can be requested by the applicant or by an authorized representative2. If you hold power of attorney for your parent, or you're the authorized representative on the application, you can usually act for them.
Read the notice carefully
The denial or change notice is the most important document in the appeal. Federal rules say the notice must explain what action the agency intends to take, the reasons, the specific rules that support it, and how to request a hearing67. Look for:
- The date it was mailed. Your deadline counts from here2.
- The reason. Excess assets, excess income, missing verification, a transfer penalty, or a finding that your parent doesn't need a nursing home level of care.
- The effective date. For people already on Medicaid, the date the change takes effect. Agencies generally must mail notice at least 10 days before reducing or ending benefits7.
- How to appeal. The address, phone number, fax or online portal, and any form.
Common reasons for denial
- Missing documents. The agency asked for a bank statement or proof of income and didn't get it, or didn't log it. This is one of the easiest denials to fix.
- Assets over the limit. Sometimes the agency counted an asset that should be exempt, like a home in some cases, a car, or a prepaid funeral plan. See Medicaid spend-down.
- Income over the limit. Some states allow a spend-down or a special trust for income over the limit.
- A transfer penalty. Gifts in the 60 months before applying can lead to a penalty period. See the Medicaid look-back period. Gifts made for a reason other than qualifying for Medicaid may be defensible8.
- Level of care. For nursing home or waiver services, the state may find your parent doesn't need that level of care. Medical records and a doctor's letter matter most here.
- Spousal rules. When one spouse applies, protections for the spouse at home are complex and errors happen. See paying for a nursing home.
How to appeal, step by step
- Mark the deadline. States set the deadline, but it can't be more than 90 days from the mailing date2. Some states allow much less time. Don't wait.
- Call the caseworker. Sometimes a missing document can be resubmitted and the case reopened without a hearing. Ask, but file the appeal anyway if the deadline is close.
- Request the hearing in writing. Use the state's form or a signed letter with your parent's name, case number, the notice date, and a sentence saying you're asking for a fair hearing. States must accept requests by mail and in person, and generally by phone and online too2. Keep a copy and proof of the date sent.
- Ask to keep benefits. If your parent is already on Medicaid, say clearly that you want benefits to continue.
- Request the case file. You have a right to see the documents the agency relied on1.
- Gather evidence. Bank statements, proof of payments, medical records, letters from doctors. Write a short timeline.
- Prepare witnesses. A doctor's letter, or a family member who can explain what was spent and why.
- Attend the hearing. Many are by phone. Bring copies of everything.
Keeping benefits during the appeal
For someone already on Medicaid, timing matters. If the agency sends advance notice and your parent asks for a hearing before the date the action takes effect, the agency generally can't end or reduce services until a decision is made3. If the hearing decision goes against your parent, the agency may try to recover what it paid for services during the appeal, to the extent state rules allow3. Ask your legal aid office whether continuing benefits makes sense in your situation.
This matters most for people in a nursing home or using a home care waiver, where a gap in coverage can mean a large private bill or a loss of services.
What happens at the hearing
A hearing officer who wasn't involved in the original decision runs the hearing1. Your parent or their representative can present evidence, bring witnesses, question the agency's evidence, and bring a lawyer or other helper1. Hearings are usually informal. The agency's caseworker explains the decision, then you explain why it's wrong.
Keep your case focused. If the denial said your father had too much in a savings account, show the statement proving it was spent on his care or that it belongs to someone else. If the problem was a missing document, bring it. Connect each piece of evidence to the specific rule in the notice.
The state generally must take final action within 90 days of the hearing request, and faster in expedited cases where waiting could seriously harm your parent's health9. The decision must be in writing and based only on the evidence at the hearing9.
Appealing a level-of-care denial
Some denials have nothing to do with money. For nursing home coverage or a home and community based waiver, the state also decides whether your parent needs that level of care, usually after an assessment by a nurse or social worker. A short assessment on a good day can miss how much help your parent really needs. People with dementia, for example, may answer questions well while still being unable to manage medications, cook safely or remember to eat.
For this kind of appeal, the strongest evidence is medical. Ask your parent's doctor for a letter that lists diagnoses, describes the help needed with daily activities like bathing, dressing, toileting and moving, and explains any safety risks such as falls or wandering. A log kept by family over two weeks, noting each time help was needed, can be persuasive. If your parent lives in a community, ask staff for care notes. Our guides to signs it's time for memory care and fall risks can help you describe what you're seeing in concrete terms.
If your parent is in a nursing home and the denial could lead to a discharge, tell the facility right away that you've appealed. Residents have discharge protections, explained in our guide to nursing home discharges.
If you lose
The written decision should explain any further appeal rights, which in many states include a review by a higher state office or a court. Deadlines for those steps are often short. You can also reapply at any time, for example after spending down excess assets or after a penalty period ends. A new application may be faster than further appeals when the facts have changed.
Where to get free help
- Legal aid. Legal Services Corporation funds local legal aid programs across the country; many handle Medicaid appeals for low-income older adults4.
- Senior legal services. Older Americans Act legal programs serve people 60 and older; your Area Agency on Aging can connect you512.
- An elder law attorney. For complex asset or trust questions; a lawyer who focuses on Medicaid planning can review the case. Ask legal aid for names.
- The long-term care ombudsman. If your parent is in a nursing home facing discharge because of a denial; see the ombudsman program.
An example
Ray's mother applied for Medicaid to cover her nursing home. The denial said she had assets over the limit, counting a certificate of deposit. Ray's sister had actually cashed that CD six months earlier to pay the nursing home, but the agency only saw the old statement. Ray requested a fair hearing within the deadline, asked for the case file, and brought the bank record showing the payment to the nursing home. The hearing officer reversed the denial. This is an illustration; results depend on the facts and state rules.
Tips that make a difference
- Keep a contact log. Write down every call with the agency: date, name and what was said.
- Send documents in a way you can prove. Use certified mail, a fax confirmation, or an upload receipt.
- Organize evidence by issue. One folder per reason in the notice.
- Be polite and persistent. Caseworkers handle heavy loads. A clear, organized packet gets attention.
- Don't miss the hearing. If you can't attend, ask to reschedule in writing before the date.
- Ask about interpreters. If your parent or family needs an interpreter, ask for one when you request the hearing so it is arranged in advance.
