Appeal a Medicaid Denial: 2025 Step-by-Step Guide

Appealing a Medicaid denial is time-sensitive—but very doable. Most people can request a state fair hearing and, if they act fast, keep benefits during the appeal. Your exact deadline comes from federal rules and your state’s notice. This guide shows the steps, scripts, and timelines to use. Legal Information Institute+1

Disclaimer: This guide is general information, not legal advice. Deadlines and procedures vary by state and program. Always check your denial notice and your state Medicaid agency.

Quick answer: How to appeal a Medicaid denial today

1. Find the deadline on your notice (often 30, 60, or up to 90 days). If it’s a managed-care decision, you typically must appeal to your plan within 60 days first. MedicaidLegal Information Institute
2. Ask for “continuation of benefits” when you appeal—ideally before the effective date or within 10 days of the plan’s notice. eCFR
3. Submit your appeal in writing (online/phone is OK where allowed) and keep proof (screenshot, fax receipt, certified mail). Your hearing must be before an impartial official. eCFR
4. Prepare evidence: your notice, medical letters, prescriptions, visit notes, eligibility proofs, and the law/regulations your notice cites. eCFR

Bottom line: File on time, ask for continuation, and collect evidence early.

Read your notice (and check for errors)

By federal rule, a Medicaid notice must clearly state the action, effective date, specific reasons, the regulations or law, and how to appeal. If the notice is unclear or wrong, say so in your appeal. eCFR

• For cuts/terminations, states generally must give 10 days’ advance notice (limited exceptions). eCFR
• In managed care, plans must send a timely, adequate notice of any adverse benefit determination. eCFR

Bottom line: If the notice doesn’t list reasons + law + appeal rights, flag that defect—it can win cases. eCFR

Appeal deadlines & decisions: what’s typical in 2025

State fair hearing (all Medicaid):

• States must let you request a hearing within a reasonable time not to exceed 90 days from the date the notice was mailed. Some states set 30 or 60 days—follow your notice. Legal Information InstituteMedicaid
• Final administrative decision usually within 90 days of your request (special counting rules for MCO cases). eCFR

Managed care plan appeals:

• File with your plan within 60 days of the adverse benefit determination. Legal Information Institute
• Plan must decide standard appeals in ≤30 days (may extend 14), or expedited in 72 hours. eCFR
• After an adverse plan appeal decision (or if the plan misses deadlines), you may go to a state fair hearing. Legal Information Institute

Bottom line: Know your clock. 60 days for plan appeals; 30–90 days for fair hearings; 90-day decision rule for state hearings. Legal Information Institute+1eCFR

Keep benefits during appeal (“aid continuing”)

If you request a hearing before the effective date (or within the required window), the agency may not terminate or reduce services until the hearing decision, with limited exceptions. For MCO enrollees, “timely filing” for continuation means within 10 days of the plan’s notice or before the effective date—whichever is later. If you lose, the plan/state may recover the cost of services paid during appeal. Legal Information InstituteeCFR

Say this when you file:

“I am requesting continuation of benefits pending appeal under 42 CFR 431.230 (and 42 CFR 438.420 if enrolled in managed care).”

Bottom line: Ask for continuation in writing—and understand the recoupment risk if you ultimately lose. eCFR

Managed care vs. Fee-for-Service (FFS): which path is yours?

Comparison table: Medicaid appeals at a glance

Topic	Managed Care (MCO)	Fee-for-Service (FFS)
First step	Appeal to your plan	Request state fair hearing
Filing deadline	60 days from plan’s adverse notice	As your state sets (30–90 days; not to exceed 90)
Decision time	30 days (standard), 72 hrs (expedited), +14 possible	State decision in ~90 days from hearing request
Continuation of benefits	Request within 10 days / before effective date	Request before effective date of action
After plan decision	State fair hearing if plan upholds or misses deadlines	N/A
Notice rules	42 CFR 438.404 content/timeliness	42 CFR 431.210–.214 content/advance notice

Sources: 42 CFR 438.402–.408, .420; 42 CFR 431.210–.214, .221, .244. Last checked: September 7, 2025. Legal Information Institute+1eCFR+3eCFR+3eCFR+3

Bottom line: Identify your program (MCO vs FFS) and follow the right lane from day one.

Build your case: evidence & law

Your burden is to show the denial was wrong on the facts or law. Collect:

• The denial/termination notice and any plan clinical rationale. eCFR
• Medical evidence (doctor letters, treatment notes, test results, ADL needs).
• Eligibility proof (income, residency, citizenship/immigration documents).
• The specific regulation your notice cites—and any contrary rule (e.g., coverage criteria, prior authorization standards). eCFR
• Interpreter or disability accommodation requests if needed (state must ensure meaningful access).
• Chronology of contacts and denials.

Bottom line: Build a paper trail that ties facts to the rule your state/plan should have applied.

Requesting the hearing: scripts, forms & where to file

Where to file:

• Managed care first: File your plan appeal (phone/online/writing per notice). Then, if needed, file for a state fair hearing after the plan’s adverse appeal decision (or if the plan misses deadlines). Legal Information Institute
• FFS or eligibility denials: File your state fair hearing directly with the state hearings office (often online, phone, mail, or fax). Examples: California and New York publish online/phone hearing request options. California Department of Social Servicesotda.ny.gov

What to say (adapt as needed):

• “I request a Medicaid fair hearing on the decision dated [date] to [deny/terminate/reduce] [benefit]. The notice did not correctly apply [policy/reg cite] and lacks adequate reasons. I also request continuation of benefits pending appeal.” eCFRLegal Information Institute

Bottom line: File in writing, include your notice date, and ask for continuation.

What happens at the hearing (and when to expect a decision)

Hearings must be conducted at a reasonable time/place (often by phone/video), after adequate written notice, and by an impartial official uninvolved in the initial decision. States must usually decide within 90 days of your request (for MCO cases, special counting rules apply). eCFR+1

Pro tips:

• Ask for your case file and evidence packet in advance; you have rights to review.
• Prepare a brief outline: issues, facts, exhibits, regulation.
• Bring witnesses (treating providers, caregivers).
• If urgent harm is likely, ask for an expedited appeal/hearing where allowed (MCO 72-hour standard). eCFR

Bottom line: Treat the hearing like a structured conversation about evidence + rules—be concise and on-point.

Checklist: 10 steps to appeal a Medicaid denial in your state

1. Calendar your deadline (look at the notice: 30/60/90 days; MCO plan appeals = 60 days). Legal Information InstituteMedicaid
2. Request continuation in the same submission (mention 42 CFR 431.230/438.420). Legal Information InstituteeCFR
3. Submit appeal in writing (online/phone allowed in many states). Keep proof.
4. Identify your lane (MCO vs FFS) to know whether a plan appeal is required first. Legal Information Institute
5. Ask for your case file and any clinical rationale.
6. Gather evidence (medical letters, test results, functional assessments, financial docs).
7. Cite the rule from your notice; bring a copy to the hearing. eCFR
8. Prepare testimony (what changed, why criteria are met).
9. Attend hearing (phone/video/in-person); request interpreter if needed. eCFR
10. Watch for the decision (generally within 90 days); if unfavorable, consider rehearing/judicial review, or reapply if facts changed. eCFR

Sensitive facts & “Source” stamps

• Fair hearing request window: States must allow up to 90 days from notice; some set 30 or 60. Source: 42 CFR 431.221; Medicaid.gov Factsheet. Last checked: September 7, 2025. Legal Information InstituteMedicaid
• Advance notice & content: 10-day advance notice in most cut/termination cases; notices must include reasons, law, and appeal rights. Source: 42 CFR 431.211, 431.210. Last checked: September 7, 2025. eCFR+1
• Plan appeals & timelines: 60-day filing, 30-day standard decision (+14 extension) or 72-hour expedited; state hearing after plan appeal or if deemed exhausted. Source: 42 CFR 438.402, 438.408. Last checked: September 7, 2025. Legal Information InstituteeCFR
• Continuation of benefits: Request before effective date (or within 10 days for MCOs) to keep services; potential recoupment if you lose. Source: 42 CFR 431.230, 438.420. Last checked: September 7, 2025. Legal Information InstituteeCFR
• Final decision timing: Generally within 90 days of request (special rule for managed-care counting). Source: 42 CFR 431.244; CMS guidance. Last checked: September 7, 2025. eCFRMedicaid

If you lose: options

• Ask about reconsideration (some states allow).
• Judicial review (state court) — strict filing deadlines.
• Reapply if your facts change (new medical evidence, income/residency corrections).
• Seek help: legal aid/health law advocates; your state Medicaid office can direct you to assistance. Medicaid

Bottom line: A loss isn’t the end—new facts or procedural errors can support a new application or review.

FAQs

1) How long do I have to appeal a Medicaid denial?
It varies by state, but federal rules require states to allow up to 90 days from the date your notice was mailed (some set 30 or 60). Check your notice. Legal Information InstituteMedicaid

2) Can I keep my benefits during the appeal?
Often yes—if you request a hearing before the effective date (or within the required window). In MCOs, timely = within 10 days of the plan notice or before the effective date. Legal Information InstituteeCFR

3) I’m in a Medicaid managed care plan—where do I start?
Start with a plan appeal (usually within 60 days). If the plan upholds the denial—or misses deadlines—you can request a state fair hearing. Legal Information Institute

4) How fast will the state decide my hearing?
States generally must issue a final decision within 90 days of your request (special counting rules for MCO cases). eCFR

5) What has to be in my denial notice?
The action, effective date, specific reasons, regulations/law, and how to appeal. eCFR

6) Will I owe money if I lose after getting aid continuing?
Possibly. Plans/states may recoup the cost of services paid during appeal if you lose. eCFR

7) Do I need a lawyer?
Not required, but legal aid/advocates can help—especially in complex medical necessity cases. Your state’s site lists contacts. Medicaid