Medicaid Fair Hearings and Appeals

Every Medicaid applicant and recipient has a legal right to a fair hearing: an independent review of a decision by someone who did not make it. Fair hearings are how families challenge a denial, a transfer penalty, a wrong patient liability, a level-of-care decision, a reduction in home care hours, or a state’s failure to decide an application in time. This guide explains how the process works, what to expect, how to prepare, and how to keep benefits in place while an appeal is pending.

Figures change periodically. Double-check current amounts before relying on them.

What a fair hearing is

A fair hearing is an administrative proceeding, not a court trial. It is usually held before a hearing officer or administrative law judge employed by the state (often in a separate office from the Medicaid agency). The hearing may take place by phone, by video or in person. The applicant (or their representative) and the agency each explain their side and present evidence, and the hearing officer issues a written decision.

Federal rules require states to offer a fair hearing when:

an application is denied;
a decision is not made with reasonable promptness;
benefits are reduced, suspended or ended;
a service is denied, reduced or ended;
the person believes the agency acted incorrectly in some other way that affects their benefits.

What can be appealed

Common long-term care issues heard at fair hearings include:

denial for excess assets or income;
treatment of a trust, annuity, life insurance policy or retirement account;
a transfer penalty and its length;
whether a transfer was for fair value or exempt;
the patient liability amount;
the spousal allowances, including requests to raise the community spouse’s share because of exceptional circumstances or income needs;
a level-of-care decision;
the number of home care hours or a waiver service denial;
a nursing home discharge (heard in a related process);
estate recovery hardship decisions, in many states.

Deadlines

The notice of the decision must state the deadline to request a hearing. Federal rules allow states to set a reasonable deadline of up to 90 days from the date the notice was mailed. Many states set shorter deadlines. Mark the deadline the day the notice arrives.

Keeping benefits during the appeal

If a person already receiving Medicaid gets notice that benefits or services will be reduced or ended, they can often keep benefits unchanged while the appeal is pending, if they request a hearing before the date the action takes effect (the state generally must give at least 10 days’ advance notice). This is sometimes called “aid paid pending” or “continued benefits.” If the person loses the appeal, the state may seek repayment of benefits paid during the appeal, so families should weigh that risk.

Managed care plans

If long-term care is delivered through a managed care plan, there is usually a plan-level appeal first. Under federal managed care rules, members generally have 60 days from the notice to file a plan appeal, the plan must usually decide within 30 days (or 72 hours for an expedited appeal when health is at risk), and if the plan upholds its decision, the member can then request a state fair hearing. Benefits can continue during the plan appeal if it is filed within 10 days of the notice or before the change takes effect. See Managed long-term services and supports.

How to request a hearing

Use the method on the notice. Many states accept requests by mail, fax, phone, online or in person. A written request is best because it creates a record.
Include the basics: the applicant’s name, case number, the decision being appealed (attach a copy of the notice), and a short statement that you are requesting a fair hearing.
Ask for continued benefits if applicable.
Keep proof that the request was sent and received.

You do not need a lawyer to request a hearing, and the request does not have to explain the whole argument.

Before the hearing

Get the case file

You generally have the right to see the agency’s case file and the documents it will use at the hearing, before the hearing. Ask for them in writing. Reviewing the file often reveals the exact error, for example a document the agency never received or a misread statement.

Gather evidence

Evidence that helps at hearings includes:

documents the agency did not have or misread (statements, contracts, deeds, trust documents);
letters from banks, insurers or funeral homes explaining a product’s terms;
receipts and written explanations for transfers;
appraisals or broker opinions of value;
medical records and letters from doctors and caregivers about care needs;
written statements from people with firsthand knowledge.

Talk to the agency

Many cases are resolved before the hearing, when the caseworker or a supervisor reviews new evidence. Some states hold an informal conference first. It is fine to try to settle, but do not withdraw the hearing request until the issue is fixed in writing.

Prepare a short summary

Write a one- or two-page summary: what happened, what the agency decided, why it is wrong, and what you are asking for. List each piece of evidence. Bring copies for the hearing officer and the agency.

At the hearing

The hearing officer explains the process, usually swears in witnesses and records the hearing.
The agency usually goes first, explaining its decision.
You present your side: your summary, evidence and witnesses. You can question the agency’s witnesses.
Stay calm and factual. The hearing officer decides based on the rules and the evidence.
Ask for time if new evidence comes up that you need to respond to.

Hearings are often short, from 30 minutes to an hour or two.

After the hearing

The hearing officer issues a written decision. Federal rules generally require a final decision within 90 days of the hearing request (shorter for expedited cases involving urgent health needs). If you win, the agency must correct the decision, often back to the original date. If you lose, the decision explains further appeal rights, which may include an agency review and then a court appeal, usually with short deadlines.

Hearings to raise the spousal allowances

A fair hearing is one of the main ways a married couple can raise the protected amounts for the spouse at home. If the spouse at home’s income is below the minimum allowance even after receiving the applicant’s income, or if there are “exceptional circumstances resulting in significant financial duress,” a hearing officer may raise the income allowance or the resource allowance. In many states, the resource allowance can be raised if more assets are needed to produce enough income for the spouse at home. These hearings call for careful financial evidence. See Raising the allowances.

Nursing home discharge appeals

Residents of Medicaid- or Medicare-certified nursing homes can appeal a proposed discharge or transfer. The facility must generally give 30 days’ written notice (shorter in some emergencies), state the reason and explain the appeal right. In most cases, a resident who appeals cannot be discharged while the appeal is pending. The long-term care ombudsman program can help at no cost. See Nursing home discharges and evictions.

A worked example

Henry’s patient liability is set at $2,450 a month. His wife, Rose, lives at home on $1,100 a month of Social Security. The notice gives her a spousal income allowance that does not count her property taxes and homeowners insurance, which would raise her shelter costs and her allowance. Her son requests a fair hearing, asks for the case file, and finds the agency never received the tax bill. He sends the tax and insurance bills with a short summary. Before the hearing, the agency recalculates: Rose’s allowance rises, and Henry’s patient liability drops by several hundred dollars a month, back to the date of approval.

Getting experienced help

Many fair hearings are won on careful preparation: the right document, a clear explanation and an accurate reading of the state’s rules. A Certified Medicaid Planner can review the decision and the case file, gather the evidence and, depending on state rules, represent the family or work alongside an attorney. Free legal aid programs also help with hearings for people who qualify. As a rough guide, hourly rates for help with appeals and hearings range from about $150 to $600, and some professionals charge a flat fee. See How free legal aid works.

Frequently asked questions

Do I need a lawyer? No, but legal or experienced help can make a difference, especially in complex cases about trusts, transfers or spousal allowances.

Can a family member represent the applicant? Usually yes, with written authorization.

Will the hearing be in person? Many states hold hearings by phone or video. Ask if you need accommodations.

What if I miss the deadline? Some states allow a late hearing request for good cause. Otherwise, a new application may be the only option.

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.