Medicaid Appeals Part 1: Filing a Hearing

When you disagree with a Department of Health and Human Services decision, you have the right to file an appeal. But how do you do that? What happens? Do you need a lawyer?

In the interest of time and communication, it is always preferable to attempt to contact your caseworker and resolve the problem. But sometimes that just doesn’t happen. Also, if you have already received a denial letter, generally your choices are to file a hearing request OR reapply. If you decide to file a hearing, you need to fill out a hearing request form and turn it in as soon as possible. If you are not able to turn the hearing in at your local DHHS office,  you can fax the completed form to (517)346-9888.  

NOTE: You can request hearings for any programs that DHHS offers, not just Medicaid.

Reasons to File a Hearing Request

Income discrepancy

You may be denied for being over the income limits for your benefit program. For many people, their income is not straightforward. If you are self-employed or a seasonal worker, your income may vary from month to month or year to year. If you disagree with the income on your Determination Letter, you should file a hearing. 

Standard of Promptness

DHHS has a 45 day standard of promptness for processing applications. If you have not received a Health Care Coverage Determination Letter within 45 days of your application, you should file a hearing.  

INCORRECT DETERMINATION

Your letter may state that you are eligible for a MA Deductible or MA Spend down. This is a Medicaid program for people who are over income for Medicaid.  (Read more about Deductible and Spenddown here.)  A Medicaid deductible is not Minimum Essential Coverage and you will incur a tax penalty if it is your only coverage.  If you believe you or your children are eligible for full Medicaid, you should file a hearing.  

“You failed to return… documents.”

You may get a letter that says you failed to return a document or requested verification. If you have proof that you did turn in the documents by the due date listed on the letter, you should file a hearing. It is always best to upload or fax documents to DHHS.  When you upload a document to your MiBridges account, it appears directly into your account. When you fax a document, it is scanned and added to your account. Always keep proof of any faxes sent to DHHS. It proves you returned the required documents on time. Mailing documents back to DHHS is not recommended. You do not have proof that you mailed your documents back and frankly, mailed documents rarely make it into your account.

Remember—when a caseworker requests a document by a certain date, you can request two 10-day extensions. Again, it is best to have proof that you have requested an extension by either emailing your caseworker or faxing a request.

Immigration Issues

“I am eligible for full Medicaid but I have Medicaid Emergency Services Only.”  

OR  

“I am only eligible for Medicaid Emergency Services Only but have full Medicaid.”

If you are a US Citizen and you are income eligible, you should receive full Medicaid.  If you are not a US Citizen and you are not a qualified immigrant, you are eligible for Medicaid Emergency Services Only (ESO). It is tricky to answer the questions on the Medicaid application and sometimes caseworkers make mistakes about who is eligible and who is not eligible for full Medicaid and Medicaid ESO.  [If you are pregnant, you can get Medicaid ESO and a special coverage called MOMS.]  If you are unsure about your eligibility or have any questions, please call the Washtenaw Health Project at 734-544-3030. We have in-person assistance in English, Spanish, French, and Arabic, and phone translation assistance for other languages. The Michigan Immigrant Rights Center is also a good resource.  

The Request For Hearing Form

The Hearing Request Form is located here.  You can download and print it. Fill out the request with all your information: Case Name, Case #, contact information, and your caseworker’s name. State the reason you are filing the hearing. You don’t need to give a lot of detail. 

“My family was denied Medicaid for being over income but we are eligible.”

“I was denied for not returning requested documents on time but I faxed the documents on August 8, 2016 which was before the due date of August 10, 2016.  Attached is proof of my fax.”

“My children are eligible for MIChild.” 

“I applied 2 months ago and have not received any letters about my health care.”

You can attach relevant documents to the hearing and explain the situation further if you want, but this is not required.  

Make sure you submit the Hearing Request before the deadline. The deadline is listed on the last page of your Denial or Determination Letter. If you want to meet the caseworker and supervisor in person, make sure to request an In-Person Hearing.  Write “In-Person Hearing Requested” on your form. 

That’s it. Fill it out and turn it in. The next blog will explain the Hearing Process!  

Medicaid Appeals Part 2: The Hearing Process

Resources:

Hearing Request Form

Legal Services of South Central Michigan (LSSCM)

Michigan Immigrant Rights Center