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Protect your Medicaid rights - Ask for a fair hearing

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Protect Your Medicaid Rights

 

PROTECT YOUR MEDICAID RIGHTS 

If you have Medicaid problems, ask for a fair hearing. 

 

If you have problems with Medicaid, you have rights: 

  • WRITTEN NOTICE. You have the right to a written notice when the state plans to cut off your Medicaid, deny you services, or take any other action that is unfavorable to you* The notice must include the reasons for the action. 

  • NOTICE BEFORE THE STATE CUTS OFF YOUR MEDICAID. In almost all cases, you have the right to 10 days notice before the state cuts off your Medicaid.* 

  • A FAIR HEARING. If you disagree with a decision the state makes, you have the right to a fair hearing. Call your county Department of Family and Children’s Services (DFCS) to ask for a fair hearing. 

* Always keep the envelope! You may need to show when you got the notice. 

 

What is a fair hearing? 

A fair hearing is a chance to get state officials to change their decision about your case. An independent judge from the Office of State Administrative Hearings will hear your case. The judge will listen to you, listen to Medicaid workers, read the law, and write a decision. You can represent yourself or you can take a lawyer or other person to represent you. You should receive a written decision within 90 days after you ask for the hearing. Sometimes your problem can be solved even before the hearing. Make sure you really agree with what the state is doing before you cancel the hearing. If you are not sure, it is better to go to the hearing and talk to the judge. 

 

How do I get a fair hearing?

You usually have 30 days from the date on the notice to ask for a fair hearing. If you ask for a hearing within 10 days, you can keep getting Medicaid while you appeal. (If you lose, the state could ask you to pay back benefits it paid while you appealed.) Call or visit your county Department of Family and Children’s Services (DFCS) to ask for a fair hearing. You must send DFCS a request in writing within 15 days after you first ask for the hearing if you did not do it in writing at that time. Also, send a copy of your hearing request to the address listed on the notice you received. 

 

Times when you may want to ask for a Medicaid fair hearing: 
  • You apply for Medicaid, but are told you are not eligible 

  • You are not allowed to apply for Medicaid when you ask 

  • DFCS takes more than 45 days to make a decision on your application (90 days if based on disability) 

  • Your Medicaid is cut off 

  • Your doctor, pharmacist, transportation broker, dentist, or another health care provider tells you Medicaid will not pay for a service you need. If you are in a CMO (care management organization), you may need to file an appeal with the CMO before asking for a fair hearing. 

  • Medicaid does not pay for a service you have already received 

  • The state decides you cannot have nursing home care or services under the Community Care Services Program, SOURCE, the Independent Care Waiver, or another waiver program 

  • Services Medicaid has been paying for are stopped and you believe they should not be stopped 

  • You have any other problem with Medicaid 

 

If you need more information, contact the office of Georgia Legal Services or Atlanta Legal Aid in your area.

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Last Review and Update: Jul 14, 2015