Medicaid Appeals and Fair Hearings: Strategies for Elder Law Counsel

Individuals may find themselves facing denials of Medicaid coverage for needed services or benefits for a host of reasons, including missing or incomplete documentation and disallowed transfers of funds or assets. Medicaid rules provide that applicants and beneficiaries who have received an adverse determination—whether a denial, reduction or termination in coverage—have the right to an administrative fair hearing before the state agency that administers the Medicaid program. Beneficiaries who receive an adverse hearing decision may then seek judicial review of the decision in state court.

Because Medicaid is a federal program administered by the states, appealing an adverse decision requires navigating both federal and state constitutional and statutory procedures. A Medicaid appeal can be a lengthy and complicated endeavor. Elder law counsel must be thoroughly familiar with the fair hearing process and other Medicaid administrative rules to ensure that clients take advantage of their procedural and substantive rights and reach a resolution that ensures they receive the needed benefits.

Listen as our experienced panel of elder law attorneys provides guidance in navigating Medicaid fair hearings and the appeals process. The panel will discuss advocating on behalf of Medicaid applicants and beneficiaries facing reductions, terminations or denials of coverage; outline the steps required to prepare for a fair hearing and the critical timing issues; and explore strategies for litigating appeals in administrative fair hearings and state court.

1. Medicaid appeal and fair hearing rules
2. Jurisdictional issues
3. Overview of common reasons for denials
4. Discovery and appeal strategies
5. Best practices for avoiding Medicaid denials
6. When a federal court action may be appropriate and how to go about it

The panel will review these and other relevant issues:

• What actions and inactions entitle applicants or beneficiaries to notice and hearing rights?
• What types of documents, evidence and testimony can be submitted at a fair hearing?
• What common application errors can lead to a denial of Medicaid coverage?