Medicaid: benefits continue while you appeal, if you ask in time
When a Medicaid agency or managed-care plan reduces or ends a service you are already receiving, you can keep the service during the fair hearing by requesting the hearing before the effective date (or within ten days of the notice). Most people lose the service because nobody told them to ask quickly.
When it applies
- Terminations or reductions of ongoing Medicaid services: home care hours, therapy, medications, DME, waiver services
- Medicaid managed-care plan appeals, which precede the state fair hearing
Where it does not
- Initial denials of a service never yet provided (no benefit to continue)
- Medicare and commercial plans (Medicare Advantage has its own fast-track continuation for terminations)
The sentence to put in the appeal
“I request a fair hearing on the [date] notice reducing/terminating [service] and, under 42 CFR 431.230(a), I request that services continue at the current level pending the hearing decision. This request is made before the effective date of the action / within ten days of the notice.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Act on the notice date, not the effective date
Ten days from the notice, or before the action takes effect, whichever protects you.
- Step 2
Use the plan appeal first where required
Managed-care members generally appeal to the plan first and can ask for continuation there too; the state hearing follows.
- Step 3
Keep the service log
If you lose, the state may seek recovery of continued benefits; if you win, the record of need is already built.
Worked example
Home-care hours were cut from 40 to 20 a week. The family requested the hearing within ten days with aid continuing; hours stayed at 40 for the four months until the hearing, which restored them.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours, tells you in writing which rules apply and whether it can be appealed, and Apellica prepares the appeal with the citations. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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