Medicaid: your appeal 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. You generally have up to 90 days from the date of the notice to request the hearing (120 days if you are requesting it after a Medicaid managed-care plan appeal). 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.

Federal Medicaid law protects access to covered outpatient drugs: even a drug excluded from the state program's preferred list must remain obtainable through prior authorization, the state's prior-authorization system must respond within 24 hours of a request, and at least a 72-hour emergency supply must be dispensed while a decision is pending. If a managed-care plan administers your drug benefit, these protections operate through your state's program — cite them and ask the plan and the state Medicaid agency which entity is responsible.

Under the 2026 CMS prior-authorization rule (CMS-0057-F), impacted payers — Medicare Advantage plans, Medicaid and CHIP (fee-for-service and managed care), and Qualified Health Plans on the federal Marketplace — must give a specific reason for a prior-authorization denial, not boilerplate. Ask for the exact criteria used, the guideline relied on, and the reviewer's credentials. A vague, non-specific denial gives you strong grounds to challenge the decision. (This rule does not reach most commercial or self-funded employer/ERISA plans.)

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. (Ground ambulance bills are not covered by these protections.)