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Medicaid Denial Reasons and the Appeals Process

Medicaid is a health care program for low-income U.S. residents. The federally mandated program, operated at the state level, covers basic health care costs such as hospital stays, doctor visits, and nursing home care. But, as with most government programs, there are eligibility requirements to qualify for coverage.

This article discusses the reasons why Medicaid coverage may be denied, as well as the process for appealing a denial, which can ultimately result in a hearing on your request for coverage.

Eligibility Requirements for Medicaid

Since Medicaid is run by state governments, the criteria for Medicaid eligibility will vary from state to state. However, the federal government provides a few guidelines for Medicaid eligibility.

First and foremost, in order to qualify for Medicaid, a person must be a lawful permanent resident or a U.S. citizen. Assuming this requirement is met, the primary factor for determining eligibility is income, which is based on the Modified Adjusted Gross Income (MAGI). Certain people may be eligible without meeting the MAGI income rules, such as those who are blind, disabled, over 65 years old, or those enrolled in the breast and cervical cancer treatment and prevention program.

Medicaid Denial Reasons

There are a variety of reasons why an applicant may be denied Medicaid coverage, assuming that they qualify.

An application for Medicaid benefits may be denied due to missing documentation, such as bank statements, tax returns, or other important documents pertaining to income or other criteria. Since the person reviewing the application will need these documents to verify eligibility, omitting these documents (whether intentionally or unintentionally) can result in a denial.

Of course, there may be times when an applicant includes all requested documents but still receives a denial. For example, they may have been lost or misinterpreted by the person reviewing the application.

In some instances, the applicant's behavior can also result in a denial. If a person transfers their assets to someone else (such as a family member) or puts the assets in a trust in order to meet the income requirements for Medicaid coverage, then their application can be denied.

The Appeals Process

The process for appealing a denial will vary depending on the state, but there are some basic federal rules that states must follow.

Written Notice of Denial. The state Medicaid agency is required to send written denial notice to the applicant. The written notice must explain why the Medicaid application was denied, the fact that the applicant has a right to appeal, how to request a hearing, and the deadline to appeal the decision. As per federal law, the state must issue the denial notice:

  • 45 days from the application date, if the application was based on something other than a disability.
  • 90 days from the application date, if the application was based on a disability.

Requesting an Appeal. Whether an applicant is required to request the appeal in writing or not will depend on state rules (and should be included in the notice). However, it's a good idea to file a written request, even if it's not required, so that there's proof that it was done within the deadline.

Appeals Hearing. The state Medicaid agency will set a date for the appeals hearing and provide information about how the hearing will be conducted. It's important for the applicant to attend the hearing because failure to appear will result in the appeal being dismissed. Under federal rules, an applicant is permitted to view the state's file on them to better prepare for the hearing.

Result of the Hearing. After the hearing, the applicant will receive a written notice of the hearing officer's decision. If the appeal is unsuccessful, the notice will explain how to appeal the hearing officer's decision. If on the other hand the appeal is successful, the applicant will be enrolled in the Medicaid program and will also receive retroactive coverage in most cases.

Learn More About Medicaid Denial Reasons and the Appeals Process from a Lawyer

While Medicaid is available for those who can't afford to buy health insurance privately, there are times Medicaid applications are denied. If you'd like to learn more about Medicaid denial reasons and the appeals process or need help through the process, you may want to consult with an experienced health care attorney near you.

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