Medicaid: your appeal rights
Medicaid's fair hearing right is powerful and underused — and if you appeal within 10 days, your services usually continue while you fight.
Is this you? Your coverage is Medicaid or CHIP — often through a managed care company (Centene, Molina, UnitedHealthcare Community Plan, and others run state Medicaid plans).
The escalation ladder
Your specific rights
If Medicaid or your Medicaid managed care plan denies, reduces, or stops a service, you can demand a state fair hearing before an impartial officer. If you appeal within 10 days of the notice, your current services usually continue while you wait.
With a Medicaid managed care plan, you generally must appeal to the plan first — within 60 days of the denial notice. The plan has 30 days to decide (72 hours if expedited). After that you can go to the state fair hearing.
Under the 2026 prior-authorization rules, impacted payers must give a specific reason for a prior-auth denial — not boilerplate. Ask for the exact criteria used, the guideline relied on, and the credentials of the reviewer. Vague denials are appealable on process alone.
Insurers must cover emergency care based on your symptoms at the time — not the final diagnosis. If a reasonable person would have thought it was an emergency, it must be covered as one, in or out of network, with no prior authorization required.
For emergency care and for out-of-network providers working at in-network facilities, you can only be billed your in-network cost sharing. Balance bills in those situations are illegal — dispute them rather than paying.
What to include in your appeal
- The notice of action (the denial/reduction letter)
- A request for aid paid pending, if within 10 days
- Treating provider's letter and relevant records
- State-specific medical necessity definition — Medicaid's is often broader than commercial criteria, especially for children (EPSDT)