How to Appeal a Medicaid Denial or Termination: A Step-by-Step Guide
The reason and the notice
How a Medicaid fair hearing works for long-term care: the federal hearing right, the deadline on your notice, aid-pending, preparing evidence and what follows.
Jurisdiction National · rules vary by stateLast updated October 9, 2026
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If a parent or spouse has received a Medicaid denial, termination or reduction notice for long-term care, the decision can be challenged by asking for a fair hearing before the state agency. Check the notice for the deadline and for how to request a hearing; the timing depends on that state's rules. A neutral hearing officer then reviews the evidence and issues a written decision.
A notice like this uses dense agency language about countable assets and effective dates. This guide walks through the appeal in order, from reading the notice to what happens after the decision. It explains how the federal framework and each state's own rules fit together for long-term-care Medicaid.
The process has six steps. Check the notice for the deadline and for how to request a hearing; the timing of each stage depends on that state's rules.
Before You Start: Key Background on Medicaid Appeals
Federal law requires every state Medicaid plan to provide "an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness" (42 U.S.C. § 1396a(a)(3)). The Centers for Medicare & Medicaid Services describes the same right. Under its Eligibility Policy page, states must offer a fair hearing for a denial, for an action the person believes was wrong, or where the state has not acted with reasonable promptness. CMS also notes that states have options for how they structure their appeals.
A fair hearing is a formal review in which a neutral hearing officer considers the evidence, and the applicant or beneficiary can present their own evidence and challenge the agency's decision.
The right to a hearing exists in every state. The procedure does not look the same in every state. Each state runs its own program, with its own agency name, request method and deadline. The notice the family received names the agency and the deadline that apply.
Before filing anything, it helps to gather three things:
the notice itself, which states the reason for the decision and the deadline
any earlier letters to or from the agency
the medical or financial records that relate to the stated reason
This page covers Medicaid for long-term care. It does not cover Medicare, private long-term-care insurance or veterans' benefits.
Step 1: Read the Notice and Identify Your Deadline
The notice is the starting point. It states the decision, the reason for it, the right to a hearing, the deadline and how to request a hearing.
A notice that reduces or ends coverage states the reason for the action and explains the hearing right; the state's rules govern when it must be sent.
Deadlines vary by state. Check the notice for the deadline and how it is measured, and confirm it with the state agency. It helps to write the notice date and the deadline somewhere easy to see.
A request made after the deadline may not be accepted. Whether the state accepts a late request depends on that state's rules. The notice or the state agency can say whether that is possible.
The type of notice matters. It helps to identify which kind of notice this is:
An initial denial says an application was refused.
A termination or reduction notice ends or cuts coverage a person already has. In these cases, coverage may be able to continue during the appeal (Step 3).
Step 2: Request a Fair Hearing
Check the notice for how to request a hearing and which methods the state accepts.
A request should identify three things:
the person whose coverage is at issue
the decision being appealed
the date of the notice
It helps to keep a copy of everything sent and, when mailing, to use a delivery method that provides proof of delivery.
Filing for someone else. Depending on the state's rules, a representative, such as a family member, an advocate or an attorney, may be able to file the request and take part in the hearing. The notice or the agency can say what permission it needs.
Confirming receipt. After submitting the request, it helps to contact the agency to confirm it was received and to ask that the hearing date be sent in writing. The next step is to wait for the agency to schedule the hearing.
Step 3: Understand Aid-Pending — Keeping Coverage While You Appeal
Aid-pending, also called continuation of benefits, concerns whether coverage continues at the prior level while an appeal of a termination or reduction is pending. Check the notice for whether and how it is available; the state's rules govern.
Aid-pending has three important limits:
It applies only to existing coverage. It covers terminations and reductions. It does not apply to an initial denial, because there is no existing coverage to continue.
Timing controls. Check the notice for the date by which a request must be made for coverage to continue; a later request may not qualify, depending on the state's rules.
Repayment may be sought. Depending on the state's rules, the state may seek repayment of the benefits paid during the aid-pending period if the appeal is unsuccessful.
The framework for aid-pending is federal, but each state administers it. The notice and the state agency are the authoritative sources for how the state applies it.
Step 4: Prepare Your Case Before the Hearing
This step is about narrowing the focus.
Reviewing the agency's file. A person can ask the agency to see the evidence it relied on before the hearing and for a copy of the case file; the notice or the agency can say how.
Answering the stated reason. The most useful evidence answers the specific reason given in the notice. Depending on that reason, this may include medical records, physician letters, bank and financial statements, or documents showing that an asset or income is exempt. Denials for long-term care often use terms like these:
Countable asset: an asset the state counts toward its eligibility limit. See Medicaid asset limits.
Community spouse: the spouse who stays at home when the other spouse enters a nursing facility or receives long-term care.
Look-back period: the period during which the state reviews transfers of assets.
Penalty period: a period of ineligibility caused by a disqualifying transfer.
Getting help. A person may handle the hearing personally or be assisted by an attorney or another authorized representative, as the state's rules allow.
Organizing the material. It helps to arrange documents in date order and to write a one-page summary that states the key facts and the specific error believed to have been made.
Planning for Long-Term Care?
Medi-Cal and Medicaid rules are complicated, and the stakes for your family are real. Reach out, and we'll listen to your situation and help you understand your options.
Check the hearing notice for the format and the location or call-in details.
The hearing officer is a neutral decision-maker and is not the person who made the original decision. The officer's role is to review the evidence and apply the rules that govern the case.
What happens at the hearing:
The agency explains the basis for its decision.
The applicant or representative presents evidence.
The applicant or representative may question the agency's witnesses or evidence.
The hearing notice or the agency can explain whether a record is kept and how to request a copy or a transcript.
After the hearing, the officer issues a written decision. How long that takes depends on the state's rules.
Step 6: After the Decision — Next Steps If You Win or Lose
If the decision favors the applicant, the decision or the state agency states how and when it is carried out.
If the decision is unfavorable, the decision states what further review, if any, is available and the deadline to request it.
Court review. Whether judicial review is available depends on the state's rules. It is a separate legal proceeding with its own rules and deadlines.
Redetermination is different from an appeal. Redetermination is the state's periodic review of whether a current beneficiary is still eligible. It is not a response to a denial. If a redetermination leads to a termination or reduction, that new notice triggers the same hearing rights described here.
Outcomes depend on the facts, the state's rules and the evidence presented. This guide does not predict any result.
Typical Timeline: What to Expect at Each Stage
Each stage of an appeal runs on its own clock, and the notice and the state's rules govern them.
Requesting the hearing. The deadline is stated on the notice and depends on the state's rules.
Scheduling the hearing. The time between filing and the hearing date depends on the state and its caseload.
Receiving the decision. The time between the hearing and the written decision is set by each state's rules.
Further review. Requesting further administrative review adds more time before court review becomes available.
The total time, from filing to a final administrative decision, depends on the state, the complexity of the issues and whether further review is sought. The notice and the state agency state the timing that applies.
Where aid-pending applies, coverage continues while the appeal is pending, subject to the repayment risk described in Step 3.
When the Process Gets More Complicated
Long-term-care appeals can turn on detailed asset and income rules. Check the notice for the reason for the decision and the rules it relies on. Background on how these programs work appears in nursing home Medicaid eligibility and in paying for nursing home care.
A transfer penalty
A transfer-penalty dispute can involve three things: the specific transfer the agency identified, its date, and whether an exception applies under federal or state law.
The look-back. Federally, the look-back reaches back 60 months for transfers made on or after February 8, 2006 (42 U.S.C. § 1396p(c)(1)(B)(i)). Each state's own period depends on its current rules.
When the penalty starts. For a transfer made on or after February 8, 2006, the penalty begins on the later of two dates: the first day of a month during or after which assets were transferred for less than fair market value, or the date on which the person is eligible for medical assistance and would otherwise be receiving institutional-level care based on an approved application for that care but for the penalty period; it does not begin during another period of ineligibility (§ 1396p(c)(1)(D)(ii)). Because of this, an older gift inside the look-back is penalized the same way as a recent one.
Spousal transfers. A transfer to the person's spouse, or to another for the sole benefit of the spouse, carries no transfer penalty under federal law (§ 1396p(c)(2)(B)(i)).
Spousal disputes involve both federal framework figures and state figures. CMS's 2026 chart, effective January 1, 2026 unless otherwise noted, sets these federal figures:
Community spouse resource standard: a minimum of $32,532 and a maximum of $162,660.
Maximum monthly maintenance needs allowance: $4,066.50.
Minimum monthly maintenance needs allowance: $2,705 in most states, effective July 1, 2026 (CMCS Informational Bulletin).
A state's own figures apply from the dates that state publishes. For one example, see Florida Medicaid planning.
The home
Federal law bars coverage of nursing facility services and other long-term-care services when a person's home equity exceeds the limit, unless a spouse, a child under 21, or a blind or disabled child is lawfully residing in the home (§ 1396p(f)(1)-(2)). The statute does not prevent using a reverse mortgage or home equity loan to reduce home equity, and the Secretary must establish a process to waive the limit in cases of demonstrated hardship (§ 1396p(f)(3)-(4)). CMS lists the 2026 home-equity limits as $752,000 at the minimum and $1,130,000 at the maximum. State rules also apply.
Estate recovery
Estate recovery is a state's claim against a beneficiary's estate after death for certain Medicaid costs it paid. Its scope depends on federal law and each state's rules. Federal law bars recovery until after the death of a surviving spouse and while a child under 21 or a blind or disabled child survives (§ 1396p(b)(2)), and a state must have procedures to waive recovery that would work an undue hardship (§ 1396p(b)(3)).
This page does not cover spend-down, trust or annuity planning, Medicare, private long-term-care insurance or veterans' benefits.
If You Would Like to Talk Through a Notice
If you would like to talk through a notice like this, you can request a consultation about your family's Medicaid and long-term-care options through Medicaid Asset Protection Group.
Planning for Long-Term Care?
Medi-Cal and Medicaid rules are complicated, and the stakes for your family are real. Reach out, and we'll listen to your situation and help you understand your options.
It depends on the state and on how complex the case is. Check the notice for the deadline to request a hearing. After that, the state's rules govern when the hearing is scheduled and when a written decision is issued. Requesting further administrative review adds more time.
Do people usually win Medicaid appeals?
No general answer applies, because outcomes depend on the facts: whether the agency's determination was accurate, how well the evidence answers the reason stated in the notice, and the state's rules.
What is the Medicaid redetermination process?
Redetermination is the state's periodic review of whether a current beneficiary is still eligible, and it is not an appeal. If a redetermination leads to a termination or reduction, the notice that follows triggers the same fair-hearing rights described in this guide.
Can I keep my Medicaid coverage while my appeal is pending?
Whether coverage continues while an appeal is pending depends on that state's rules, and the notice is the place to check how to ask for it. Aid-pending does not apply to initial denials. Depending on the state's rules, the state may seek repayment of benefits paid while the appeal was pending if the appeal is unsuccessful.
What happens if I miss the appeal deadline?
A request made after the deadline may not be accepted. Whether the state accepts a late request depends on its rules, and the state agency can say whether one is possible.
Can a family member file a Medicaid appeal on someone else's behalf?
Depending on the state's rules, a representative, such as a family member, an advocate or an attorney, may be able to file the request and take part in the hearing. The notice or the state agency states what authorization it requires.
What is a fair hearing in the Medicaid context?
A fair hearing is a formal review by a neutral hearing officer, who is not the person who made the original decision. The applicant or beneficiary can present evidence and challenge the agency's decision. Step 5 describes what happens at the hearing.
What if my Medicaid appeal involves a transfer of assets or a penalty period?
A transfer-penalty dispute can involve three things: the specific transfer the agency identified, its date, and whether any federal or state exception applies. Federally, for a transfer made on or after February 8, 2006, a penalty starts on the later of the first day of a month during or after which assets were transferred for less than fair market value, or the date the person is eligible and would otherwise be receiving institutional-level care based on an approved application for that care but for the penalty period.
