Medicaid Appeals

The Medicaid program is a joint federal and state medical assistance program for certain low-income individuals, including individuals with disabilities. Each state has its own Medicaid plan. Although the federal law requires some uniformity among states' Medicaid plans, each plan is managed by the state's own agency, and services and eligibility criteria vary from state to state.

Federal law requires every state Medicaid program to have an appeals procedure. This procedure first requires that whenever the state Medicaid agency makes a decision about eligibility for benefits, a written notice must be sent to the applicant or recipient explaining the decision.

The Medicaid Denial Notice

If an application for Medicaid benefits is denied, the written notice must specify the reason for the denial and provide enough detail to enable the applicant to determine how the decision was reached. For example, if the reason for denial of benefits is that the applicant's income was too high, the notice should identify the specific income limit used and how the income was calculated. (Income limits vary based upon a number of factors, including which Medicaid program is involved and how many individuals are in the household.)

If you receive such a notice of denial and you cannot understand the notice, perhaps you were not given enough information. Without specifics it is impossible to figure out whether the decision is based upon accurate information or is flawed in some way. The failure to provide specific information is a violation of your rights in and of itself. If you were denied benefits but cannot determine the reason, your appeal should complain not only about the denial itself, but also about the incomplete nature of the notice.

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