Disability Rights Florida Blog

Introduction 

Have your Medicaid services or programs been cut or new requests denied? Maybe your physical therapy hours have been reduced, or your request for new glasses was denied. If so, you need to know about Medicaid Fair Hearings. 

As a person with a disability, you have a legal right to both Notice of and Appeal from an agency's or Medicaid managed care companies' decision to reduce or deny your Medicaid services. 

A Medicaid Fair Hearing is a process that lets you fight against cuts or denials of the Medicaid services you need. The outcome will decide which services you receive, so it's important to take it seriously. If you think a decision about your services is wrong, you should ask for a hearing. 

However, the Fair Hearing process can be confusing. So let's break it down. 

Denial Notice & Requesting a Hearing 

Medicaid Managed Care Organizations (MCOs) or State Medicaid Agencies may sometimes cut or deny your services. If they do, you should receive a letter - called a Denial Notice. The denial notice you receive could have a different name, such as a Notice of Adverse Benefit, Determination, Notice of iBudget, or Notice of Outcome, depending on which agency is sending the Notice to you.  

There are four things that should be in the Denial Notice letter.

1. There should be a clear explanation of what is changing or has been denied. For example, maybe they are decreasing your physical therapy services from 3 days a week to 1. Or denying a request for a new prosthetic limb. 
2. There should also be a specific reason for their decision. If the letter just says that "the service isn’t medically necessary” and nothing else, that’s not enough. 
3. The MCO or state Medicaid agency must include which laws or rules they say support their decision. 
4. It’s important to know that you may have as little as 10 days after receiving the letter to request a hearing so that your services stay the same during the process. They need to tell you what they’re doing, why they’re doing it, and how you can respond. 

When you get a Denial Notice, there is a form you will fill out to request a fair hearing, and once the hearing office receives it, it issues a file number, and the person who has been denied services becomes the Petitioner.

What Happens During a Fair Hearing? 

Your fair hearing is a chance to explain why you need the services they’re denying or trying to take away.  

Before the hearing, make sure you gather plenty of evidence to support your case. Evidence might include receipts related to your medical care, or notes from a doctor. 

The hearing isn’t always in a courtroom—it’s usually over the phone. But it’s still a serious, confidential legal meeting. Several people may participate in the hearing, including witnesses, the MCO or state Medicaid agency representative, and a hearing officer who will listen to you and make the final decision.  

Make sure you explain your needs clearly and completely. The services you’re fighting for impact your everyday life.

After the hearing, the hearing officer will make a decision about your services. A written decision will be sent to you sometime after the hearing. They may disagree with you, and your services can be cut or denied. Or, they may agree with you, and your services can be approved.