{"id":355787,"date":"2018-09-26T11:08:28","date_gmt":"2018-09-26T16:08:28","guid":{"rendered":"https:\/\/content.findlaw-admin.com\/ability-law\/healthcare\/medicare-medicaid\/medicaid-denial-reasons-and-the-appeals-process.html"},"modified":"2018-09-26T11:45:44","modified_gmt":"2018-09-26T16:45:44","slug":"medicaid-denial-reasons-and-the-appeals-process","status":"publish","type":"page","link":"https:\/\/www.findlaw.com\/healthcare\/medicare-medicaid\/medicaid-denial-reasons-and-the-appeals-process.html","title":{"rendered":"Medicaid Denial Reasons and the Appeals Process"},"content":{"rendered":"\n
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Medicaid Denial Reasons and the Appeals Process<\/h1>\n
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Created by FindLaw’s team<\/a> of legal writers and editors<\/i><\/p>\n\n | Last updated\n

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The last updated date refers to the last time this article was reviewed by FindLaw or one of our contributing authors<\/a>. We make every effort to keep our articles updated. For information regarding a specific legal issue affecting you, please contact an attorney in your area<\/a>.<\/em><\/p>\n\n <\/div>\n <\/details>\n<\/section>\n

Medicaid is a health care<\/a> 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<\/a> to qualify for coverage.<\/p>\r\n

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.<\/p>\r\n

Eligibility Requirements for Medicaid<\/h2>\r\n

Since Medicaid is run by state governments, the criteria for Medicaid eligibility will vary from state to state<\/a>. However, the federal government provides a few guidelines for Medicaid eligibility.<\/p>\r\n

First and foremost, in order to qualify for Medicaid, a person must be a lawful permanent resident<\/a> 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<\/a> (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.<\/p>\r\n

Medicaid Denial Reasons<\/h2>\r\n

There are a variety of reasons why an applicant may be denied Medicaid<\/a> coverage, assuming that they qualify.<\/p>\r\n

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.<\/p>\r\n

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.<\/p>\r\n

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.<\/p>\r\n

The Appeals Process<\/h2>\r\n

The process for appealing a denial<\/a> will vary depending on the state, but there are some basic federal rules that states must follow.<\/p>\r\n

Written Notice of Denial<\/i><\/b>. 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:<\/p>\r\n