The Fine Print Nobody Hands You in Medicaid

A No Has to Come With Reasons

Medicaid rejection letters are designed to look final and to be skimmed. They are neither. If the state says no to your request or cuts a service your child is using, you get more than a form letter. You get an explanation.

The rule says: “At the time the agency denies an individual's claim for eligibility, benefits or services” (42 CFR 431.206)

The rule says: “A clear statement of the specific reasons supporting the intended action” (42 CFR 431.210)

The rule says: “The specific regulations that support, or the change in Federal or State law that requires, the action” (42 CFR 431.210)

Say: “Thank you for the notice. Could you tell me which regulation supports this decision and send me the specific reasons in writing?”

They Have to Tell You About the Hearing

A fair hearing is the reset button. It is how you ask a different person (not the state) to look at a decision and say whether the state got it right. The state has to tell you this exists, in writing, when you apply and when it denies you something.

The rule says: “Of his or her right to a fair hearing and right to request an expedited fair hearing” (42 CFR 431.206)

Here is what matters: you do not have to be a lawyer or go to the hearing alone. You can bring someone with you.

The rule says: “That he may represent himself or use legal counsel, a relative, a friend, or other spokesman” (42 CFR 431.206)

The 90 Day Ceiling, and Why to Move Sooner

The deadline for asking for a hearing is real and strict. You have 90 days from when the notice is mailed. That sounds like a lot until you realize you just got the letter, and the clock started then, and nobody told you the window was short.

The rule says: “a reasonable time, not to exceed 90 days from the date that notice of action is mailed” (42 CFR 431.221)

One more rule: the state cannot get in your way or try to stop you from asking for a hearing.

The rule says: “The agency may not limit or interfere with the applicant's or beneficiary's freedom to make a request for a hearing” (42 CFR 431.221)

If your child is on a Medicaid managed care plan, the order changes. You appeal to the plan first. Once the plan answers, you then have 90 days from the plan's decision to ask the state for a hearing. The plan should tell you the clock starts when they say no; read that notice carefully for the exact deadline.

The rule says: “An enrollee may request a State fair hearing after receiving notice under § 438.408 that the adverse benefit determination is upheld” (42 CFR 438.402)

Here is what I would do: ask for the hearing as soon as you decide to push back. Do it in writing, keep a copy, and write down the date you mailed or delivered it. The how to disagree in writing guide walks through what to say.

Notice Before a Service Stops

If the state plans to cut a service your child is already getting, you get a warning first. It cannot just end it.

The rule says: “The State or local agency must send a notice at least 10 days before the date of action” (42 CFR 431.211)

There are a few exceptions to this rule buried in other parts of the regulations, so read the notice you get carefully for the exact dates. The notice also has to explain what happens to your coverage while you ask for a hearing, which is important. Read that part.

For Children, the Bar Is Higher

If your child is on Medicaid, there is a special rule just for children. It is called EPSDT (Early and Periodic Screening, Diagnostic, and Treatment). Most families have never heard of it. That is a problem because it is powerful.

The rule says: “Health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered” (42 CFR 440.40)

The state also has to explain EPSDT to families in plain English, not legal speak. It has to tell you what is available, how to get it, and this matters: the services cost children under 18 absolutely nothing.

The rule says: “Using clear and nontechnical language” (42 CFR 441.56)

The rule says: “services provided under the EPSDT program are without cost to eligible individuals under 18 years of age” (42 CFR 441.56)

What is covered depends on your state and what your child actually needs, so you have to ask. The Paying for Care page breaks down how to ask and what to say when they tell you no.

Say: “Under EPSDT, is this service covered if my child's doctor says it is needed? If you say no, please send me the reason in writing.”

Making Too Much? One More Door

If family income is the reason Medicaid says no, read the pages on TEFRA and Katie Beckett (a state option that looks at your child's income instead of yours) and SSI deeming (how parent income stops counting). Ask your state Medicaid office directly whether it has this option and what it is called.