What You Need to Know About Medicaid and Fair Hearings

By the Legal Aid Society

Medicaid is a comprehensive health insurance program for low-income people of all ages. Medicaid covers a variety of health services including home care, nursing home, dental, vision, crisis intervention, inpatient rehabilitation, outpatient services, opioid treatment (including medication-assisted treatment), and residential treatment.

Who is eligible for Medicaid?

There are several categorically-eligible groups including individuals receiving public assistance and individuals receiving SSI.

To be eligible for Medicaid in New York, recipients must be a New York State resident, have adequate immigration status, and be below the income limit.

What are Medicaid’s immigration requirements?

Citizens, qualified aliens (e.g. lawful permanent residents, refugees, and asylees), Permanently Residing Under Color of Law (e.g., DACA, temporary nonimmigrants), and pregnant individuals are eligible for Medicaid. Individuals who are out of status (unless pregnant) are not eligible for Medicaid but may receive Medicaid for treatment of an emergency condition.

What are Medicaid’s eligibility categories?

Medicaid has two basic eligibility categories: Modified Adjusted Gross Income (MAGI) and non-MAGI. Children, childless adults ages 19 to 64 without Medicare, pregnant women, parents, caretaker relatives, and certified disabled individuals without Medicare are budgeted through the MAGI category. Adults over 65, Medicare recipients, recipients of TANF, SSI, foster care, and individuals with a disability determination are budgeted through non-MAGI. The two eligibility categories have different income limits and MAGI does not have a resource test.

What are Medicaid’s income and resource limits?

The non-MAGI 2019 income limit is $859 for a household of one and $1,267 for a household of two. The resource limit is $14,450 for a household of one and $22,800 for a household of two. There are a variety of different ways for applicants above the income limit to get Medicaid including a spend-down, pooled trust, and the Medicaid Buy-in for Working People with Disabilities.

How do I enroll in Medicaid?

Individuals eligible for Medicaid through the MAGI category can apply to Medicaid through the New York State of Health. This can be done online or over the phone at 855-355-5777.

For individuals in the non-MAGI category, Medicaid is administered through the New York City Human Resources Administration. Individuals eligible for Medicaid through the non-MAGI category can apply through their local Medicaid office.

Medicaid coverage for all categories can be retroactive for up to three months if the applicant was eligible during that time period.

Can I appeal if services were denied, reduced or discontinued?

Can I appeal if services were denied, reduced or discontinued?

Medicaid Eligibility

If you received a decision about your Medicaid eligibility, you have the right to request a Fair Hearing with the Office of Temporary and Disability Assistance (“OTDA”) within 60 days of the notice to challenge the denial or discontinuance. If it is a reduction of services, you must request a Fair Hearing within 10 days for services to remain unchanged.

Medicaid Managed Care

If you have a Medicaid Managed Care plan, you must first file an appeal with your plan called a Plan Appeal. You have 60 days to request a plan appeal. If the need is urgent, you may request that the appeal be fast-tracked. If your Plan Appeal is denied, you have a right to request a Fair Hearing with OTDA to challenge the denial within 120 days.

If you received a reduction or discontinuance of services, you must request the Plan Appeal within 10 days of the notice date or before the effective date to continue services unchanged. You then must request a Fair Hearing within 10 days of the Final Adverse Determination to continue services unchanged.

Fee-for-service Medicaid

If you have fee-for-service Medicaid, you have a right to request a Fair Hearing with OTDA to challenge the decision within 60 days of the notice.

What if I did not receive a notice?

If your Medicaid services were denied, reduced, or discontinued without notice, you can request a Fair Hearing. If you received a reduction or discontinuance without notice, you can ask for aid continuing and your services will remain unchanged until a decision is issued.

How do I request a Fair Hearing?

You can request a Fair Hearing over the phone at 800-342-3334. You can also request a Fair Hearing online.

You will then receive a notice telling you the time and location of your hearing.

Can I be represented at a hearing?

Yes. You are not required to have representation at a Fair Hearing, but if you want representation at a Fair Hearing you can call the Access to Benefits Helpline on the first and third Tuesdays of each month from 9:30 a.m. – 12:30 p.m. for Health Law and Medicaid advice and potential representation. The Access to Benefits number is 888-663-6880.

Can I get my hearing adjourned?

Yes. You can request a delay or adjournment of your hearing by calling ahead of time or appearing in person. Reasons for a potential adjournment include: you are seeking legal representation, you need more time to gather evidence, or you have an unmovable conflict.

What happens at a hearing?

At the hearing, a hearing judge called an “Administrative Law Judge” or “ALJ” will preside over your case. You will have an opportunity to present evidence demonstrating why the agency’s decision was incorrect. It is possible that a representative from the agency will be there to explain their decision.

If the issue is that your plan determined a service was not medically necessary, it is important to provide medical documentation from your providers demonstrating the medical necessity. If the issue is Medicaid eligibility, you should provide documentation showing that you are eligible. For example, if they denied your application because you are over income, bring recent pay stubs showing that you are under the income limit.

If you need a translator, one must be provided.

When will I get a decision?

A decision will be mailed to you after your hearing. It usually takes around three weeks, but the amount of time varies.
If you win your Fair Hearing and you do not feel the agency has taken the action the decision tells it to, you may request compliance with a Fair Hearing decision. You may submit a Compliance Complaint online or by calling 877-209-1134.

Disclaimer

The information in this document has been prepared by The Legal Aid Society for informational purposes only and is not legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. You should not act upon any information without retaining professional legal counsel.