Medicaid Fair Hearing Request

Purpose

This template provides a framework for requesting a Medicaid fair hearing to appeal adverse decisions including denial of eligibility, reduction of benefits, termination of coverage, or other actions affecting Medicaid services.

Critical Deadlines

IMPORTANT: Act quickly to preserve your rights

Note: Deadlines vary by state. Check your notice for specific deadlines.

Part 1: Appellant Information

Medicaid Applicant/Recipient

Authorized Representative (if applicable)

☐ Power of Attorney attached
☐ Authorized Representative Form attached
☐ Guardian/Conservator documentation attached

Part 2: Notice of Action Being Appealed

Details of Adverse Action

Type of Action (check all that apply)

☐ Denial of Medicaid eligibility
☐ Denial of specific service or treatment
☐ Reduction of services
☐ Suspension of benefits
☐ Termination of eligibility
☐ Failure to act on application within required time
☐ Transfer or discharge from nursing facility
☐ PASRR (Preadmission Screening) determination
☐ Recovery/estate claim dispute
☐ Spend-down requirement dispute
☐ Asset/income calculation dispute
☐ Other: _________________________________________

Reason Given by Agency for Action

(Copy from the notice of action):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Part 3: Request for Continuation of Benefits

CRITICAL: To continue receiving current benefits during the appeal, you must request the hearing BEFORE the effective date of the action (typically within 10 days of the notice).

☐ I REQUEST THAT MY CURRENT BENEFITS CONTINUE DURING THE APPEAL PROCESS

I understand that:
- If I lose the appeal, I may have to repay benefits received during the appeal period
- Benefits will continue at the current level until a hearing decision is made
- I am filing this request before the effective date of the proposed action

Date of this request: _______________
Effective date on notice: _______________

☐ Filed before effective date
☐ Filed after effective date (benefits may not continue)

Part 4: Grounds for Appeal

Summary of Why You Disagree

(Explain in your own words why the agency's decision is wrong):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Specific Reasons for Appeal (check all that apply)

Eligibility Issues:
☐ Income was calculated incorrectly
☐ Assets were calculated incorrectly
☐ Exempt assets were counted as available
☐ Transfer penalty was applied incorrectly
☐ Look-back period violation determination was wrong
☐ Spousal impoverishment rules were misapplied
☐ Residency requirement was incorrectly applied
☐ Citizenship/immigration status was verified

Medical/Service Issues:
☐ Service is medically necessary
☐ Treatment was prescribed by physician
☐ Level of care determination is incorrect
☐ Service should be covered under Medicaid
☐ Prior authorization was wrongly denied

Procedural Issues:
☐ Did not receive proper notice
☐ Notice was not timely
☐ Application was not processed timely (within 45/90 days)
☐ Required to provide unreasonable documentation
☐ Agency failed to assist as required

Other:
☐ Other reason: _________________________________________________

Part 5: Supporting Facts and Evidence

Statement of Facts

(Provide a detailed explanation of the facts supporting your appeal):

Background:
__________________________________________________________________

__________________________________________________________________

What happened:
__________________________________________________________________

__________________________________________________________________

Why the decision is wrong:
__________________________________________________________________

__________________________________________________________________

What should happen:
__________________________________________________________________

__________________________________________________________________

Evidence to Support Appeal

Witnesses

Part 6: Hearing Preferences

Hearing Format Preference

☐ In-person hearing
☐ Telephone hearing
☐ Video conference hearing
☐ No preference

Accessibility Needs

☐ Interpreter needed (Language: _______________)
☐ Sign language interpreter needed
☐ Wheelchair accessible location required
☐ Documents in alternate format (☐ Large print ☐ Braille ☐ Audio)
☐ Other accommodation: _________________________________

Scheduling Considerations

☐ No scheduling restrictions
☐ Preferred days: _________________________________
☐ Unavailable dates: _________________________________
☐ Medical appointments that cannot be rescheduled: _____________

Part 7: Legal Representation

Current Representation Status

☐ I will represent myself
☐ I have an attorney representing me
☐ I have a non-attorney representative
☐ I would like information about free legal services

Attorney/Representative Information (if applicable)

Part 8: Formal Request Letter

[Use this letter template or adapt for your situation]

[DATE]

[STATE MEDICAID AGENCY NAME]
Fair Hearing Unit
[ADDRESS]
[CITY, STATE ZIP]

RE: REQUEST FOR FAIR HEARING
Appellant: [FULL NAME]
Date of Birth: [DOB]
Medicaid Case Number: [CASE NUMBER]
Notice Date: [DATE OF NOTICE]

Dear Fair Hearing Officer:

I am writing to request a fair hearing regarding the [denial/reduction/termination] of my Medicaid [eligibility/benefits/services] as stated in the notice dated [DATE].

ACTION BEING APPEALED:
[Describe the specific action from the notice]

REQUEST FOR CONTINUED BENEFITS:
[If applicable] I request that my current benefits continue at the present level during the pendency of this appeal. I am filing this request within 10 days of the notice date, before the effective date of the proposed action.

REASONS FOR APPEAL:
I disagree with this decision for the following reasons:

1. [First reason - be specific]

2. [Second reason - be specific]

3. [Third reason - be specific]

SUPPORTING DOCUMENTATION:
I am enclosing the following documents in support of my appeal:
- [List each document]

HEARING ACCOMMODATIONS:
[If needed] I require the following accommodations for the hearing: [specify]

I request that this matter be scheduled for a hearing at the earliest available date. Please send all correspondence regarding this hearing to [address/representative if applicable].

Thank you for your attention to this matter.

Sincerely,

_________________________________
[Signature]

[PRINTED NAME]
[ADDRESS]
[PHONE NUMBER]

Enclosures: [List]

cc: [Attorney/Representative, if applicable]

Part 9: Managed Care Plan Appeals (If Applicable)

If you receive Medicaid through a managed care plan, you must usually appeal to the plan first before requesting a state fair hearing.

Plan Appeal Status

☐ Not enrolled in managed care plan (skip this section)
☐ Enrolled in managed care plan: _______________________________

Plan Appeal Information

☐ Plan appeal decision letter attached
☐ 120-day deadline calculated: _________________________________

Expedited Plan Appeal (If Applicable)

☐ Standard timeframe would seriously jeopardize health/life
☐ Expedited appeal requested
☐ Expedited appeal decision received: _______________________

Part 10: Submission Checklist

Required Items

☐ Completed hearing request form/letter
☐ Copy of Notice of Action being appealed
☐ Proof of mailing date (if mailing)

Recommended Supporting Documents

☐ All relevant bank statements
☐ Income verification documents
☐ Medical records supporting claim
☐ Physician statements/letters
☐ Asset valuations/appraisals
☐ Copies of any documents submitted with original application
☐ Written statement of facts
☐ Representative authorization (if applicable)

Submission Methods

☐ Mail: Send to address on notice by certified mail, return receipt requested
☐ Fax: To number on notice (keep confirmation)
☐ Online: Through state portal (if available)
☐ In Person: At local Medicaid office (get receipt)

Date Submitted: _______________
Method: _______________
Confirmation/Tracking Number: _______________

Part 11: After Filing - What to Expect

Timeline

Preparing for the Hearing

☐ Review all documents in your case file (you have the right to see them)
☐ Organize your evidence
☐ Prepare your testimony
☐ Prepare questions for agency witnesses
☐ Consider consulting an attorney
☐ Arrange for witnesses to attend

At the Hearing

You have the right to:
- Present evidence and testimony
- Question agency witnesses
- Have a representative or attorney
- Receive language interpretation
- Request accommodations for disabilities

Part 12: If You Receive an Unfavorable Decision

Options After Losing the Fair Hearing

☐ Request reconsideration (if available in your state)
☐ File appeal to higher administrative authority
☐ Seek judicial review in court
☐ Consult with attorney about further options

Deadline for Further Appeal: Check decision for specific deadline

Resources

Free Legal Assistance

• Legal Aid Society: _________________________________
• State Bar Lawyer Referral: _________________________________
• Area Agency on Aging: _________________________________
• Long-Term Care Ombudsman: _________________________________

State Medicaid Fair Hearing Contact

• Agency: _________________________________
• Phone: _________________________________
• Address: _________________________________
• Website: _________________________________

Signatures

Appellant Signature:

I certify that the information provided is true and accurate to the best of my knowledge.

Signature: _________________________________ Date: _______________

Print Name: _________________________________

Representative Signature (if applicable):

Signature: _________________________________ Date: _______________

Print Name: _________________________________

Relationship/Title: _________________________________

This template is for informational purposes only and does not constitute legal advice. Fair hearing procedures vary by state. Consult with an attorney or your state Medicaid office for specific guidance.