Medicaid Fair Hearings- A Guide to the Process

Medicaid Fair Hearings: A Guide to the Process

Medicaid is a publicly funded healthcare program administered jointly by the federal government and each state government. It provides health insurance coverage to millions of individuals and families throughout the United States. In New York alone, there were more than 7.7 million Medicaid beneficiaries at the end of 2022.

Medicaid is intended to be accessible to every qualified person who needs coverage, but many who apply are denied benefits. In many other cases, Medicaid notifies benefit recipients that the program is  discontinuing or reducing their benefits.

At Ely J. Rosenzveig & Associates, we want every Medicaid applicant or beneficiary to know that they  have the right to request a Medicaid Fair Hearing to review any Medicaid benefit denial, discontinuance, or reduction. Requesting a fair hearing is essentially the same as filing an appeal. It’s important to know that you must request a fair hearing within a designated time limit.

This blog post explains how the fair hearing process works, and what you can do to use the fair hearing procedure effectively. The attorneys at Ely Rosenzveig & Associates have extensive experience representing Medicaid claimants successfully throughout the fair hearing process. If you have questions or would like to discuss your case with one of our experienced Medicaid fair hearing lawyers, contact our office today.

What Is a Medicaid Fair Hearing?

A Medicaid Fair Hearing is a formal administrative proceeding that allows Medicaid beneficiaries to challenge decisions made by their state’s Medicaid agency regarding their eligibility or the amount of benefit coverage to which they are entitled. This process enables individuals, with or without a lawyer, to present their case and argue why they believe the agency’s decision is incorrect.

Why Might You Need a Medicaid Fair Hearing?

There are a number of different situations in which you might request a Medicaid Fair Hearing. Some people incorrectly believe that they can only appeal a denial or discontinuation of their Medicaid benefits. But any adverse decision by Medicaid that reduces or denies a requested increase in benefit coverage can also be grounds to request a Medicaid fair hearing.

Here is a list of some of the reasons that you can request a fair hearing:

Denial of Eligibility –If your application for Medicaid benefits is denied, you can request a fair hearing to challenge the decision.

Benefits Reduced or Terminated –If the Medicaid coverage you are already receiving is reduced or terminated, you can request a hearing to contest this action.

Disputes over Services –If you believe that Medicaid should cover specific medical services, treatments, or medications that have been denied, you can request a hearing to argue why the denial is unfair or incorrect.

Managed Care Plan Issues –If you are enrolled in a Medicaid managed care plan and you are dissatisfied with the quality or amount of care or services you are receiving, you can address these issues at a fair hearing.

Overpayment or Recovery Actions –In some cases, Medicaid may claim that you were overpaid or received benefits for which it claims you were not eligible. If the state agency seeks to recover funds from you, you can challenge this action through a fair hearing.

The Medicaid Fair Hearing Process: Step by Step

The first step in the Medicaid Fair Hearing process is to request a hearing. In New York, this request must be made within 60 days of the date of the Medicaid notice. In some cases, a claimant may not receive the notice until after the effective date in the notice. When this happens, the fair hearing request must be made within 10 days of the date the notice was received.

You can request a fair hearing in New York on the internet, by mail, by phone, or in person, either in NYC or in Albany. While you are not required to use an attorney for this process, an experienced attorney who knows Medicaid law and regulations can prepare the request citing grounds that are most likely to yield successful results.

In most cases, you can request and be granted continuing benefits during the time your hearing request is pending. If, for any reason, your benefits are not continued through the pre-hearing period, your case should be scheduled on a priority basis.

Pre-Hearing Conference

You can request a fair hearing in New York on the internet, by mail, by phone, or in person, either in NYC or in Albany. While you are not required to use an attorney for this process, an experienced attorney who knows Medicaid law and regulations can prepare the request citing grounds that are most likely to yield successful results.

In New York, you or your attorney can request a pre-hearing conference with the state Medicaid agency before the formal hearing. During this conference, you can discuss the issues and potentially reach a resolution without going through the formal hearing process.

Formal Hearing

If a resolution is not reached during the pre-hearing conference, the formal hearing will proceed. Here’s how it typically works:

Notice: You will receive notice of the date, time, and location of the hearing. The hearing may be conducted by telephone in New York. This notice will also include information about your right to representation and the types of evidence you can present.

Representation: You have the right to be represented at the hearing. This representation can be by a lawyer, an advocate, or another individual of your choosing. However, the most effective representative is a highly trained professional attorney who is thoroughly familiar with Medicaid and with the fair hearing process.

Evidence: You, your attorney (or other representative) can present all the evidence that supports your claim. This may include documents, medical records, witness statements, or other relevant information. You should also be prepared to answer questions and provide testimony during the hearing. Preparing and presenting evidence and witness testimony is one of the central activities of an attorney. Your attorney will prepare you for the hearing and offer you guidance on how to interact with the hearing officer.

Hearing Officer: The hearing is presided over by a specially trained hearing officer, an administrative law judge (ALJ), whose role is to ensure a fair and impartial hearing.

Decision: After considering all the evidence and testimony, the ALJ will issue a written decision. This decision will include the ALJ’s findings of fact and conclusions of law.

If the decision is in your favor, the Medicaid agency will be required to take corrective action, such as approving your benefits or reinstating them.

If the decision goes against you, you will have a number of options, including filing a lawsuit under Article 78 of the Civil Practice Law and Rules of New York State.

Compliance with the Decision

If the decision requires the Medicaid agency to take specific actions, such as restoring your benefits, the agency is legally obligated to comply. If the agency fails to follow the decision, you can then file a compliance request to force the agency to obey the ALJ’s decision.

Consult with an Experienced New York Medicaid Lawyer

No matter how you ultimately decide to proceed, everyone who receives any Medicaid notice of adverse action against their benefits should meet with a qualified and experienced New York Medicaid lawyer. Our attorneys at Ely J. Rosenzveig & Associates are always willing to discuss your options and answer your Medicaid-related questions.

Call Ely J. Rosenzveig & Associates for Medicaid Fair Hearing Assistance
Call 1.914.816.2900 or email us at: [email protected]

Ariel S. Rosenzveig
Ariel Rosenzveig

Ariel S. Rosenzveig received his Juris Doctor from the Benjamin N. Cardozo School of Law in May, 2011, and has been practicing law with the firm since August, 2011. During his summers while in law school, Ariel interned with the United States Commodity Futures Trading Commission in New York and with the Securities & Futures Commission in Hong Kong, China.

While in law school, Ariel served on the staff of the Cardozo Public Law, Policy & Ethics Journal, volunteered with the Cardozo Advocates for Battered Women, and participated in the National Institute for Trial Advocacy’s Intensive Trial Advocacy Program. Prior to attending law school, Ariel worked as an arbitrage trader for a small proprietary trading firm on Wall Street. Ariel graduated summa cum laude from Yeshiva University in 2006.

Ariel is licensed to practice law in the states of New York and New Jersey, and is a member of the New York State Bar Association (NYSBA), NYSBA’s Elder Law section, and the National Academy of Elder Law Attorneys (NAELA). In June, 2015, Ariel successfully completed a certificate program in mediation through the Program on Negotiation at Harvard Law School.

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