By, Rachel Davis, Elder & Disability Law Clinic Student, Fall 2021
As we grow older and encounter new health situations, Medicaid becomes the most effective choice of healthcare for a lot of individuals. Unfortunately, the application process can be daunting. Even with help, many applicants are rejected the first time they apply even if they may ultimately qualify for coverage. The explanation for these rejections can often be vague and difficult to understand, especially if an applicant has never applied for Medicaid before.
Many applicants may be disheartened and stop with their denial notice. However, they do not realize that they have the right to request an appeal in response to their eligibility determination. It is possible for denial notices to become acceptance letters, and the fix is oftentimes just the matter of submitting a different piece of paperwork. The appeal process begins with a few simple steps:
- First, an applicant must file their appeal within 30 days of receiving a written notice from the agency.
- An appeal may be filed by mail, online, by phone, or in person. [1] [2]
After an appeal has been filed, the Department of Medical Assistance Services (DMAS) Appeals Division will review the applicant’s information and determine whether a fact-finding hearing is appropriate.
If a hearing is granted, the applicant will be contacted with the date and time. During the hearing, the applicant and the agency will sit down and present both sides of the case. The agency will discuss why the application was denied, and the applicant will be allowed to explain why they think it should be approved. The applicant will also be allowed to present any new information that may have arisen since filing the appeal. Both sides will be allowed to ask any questions they would like to the other party to help resolve the situation.
After the hearing, the hearing officers will review all the testimony and any new evidence or documentation provided. They are then required to issue a decision within 90 days of the hearing. This decision will include:
- What you are appealing;
- An overview of all the facts of the case;
- A description of all the testimony and evidence that was presented at the hearing;
- An analysis of the case, which includes various conclusions involving state law and Medicaid policy;
- The DMAS hearing officer’s decision. [3]
The hearing officers have several options in what decision they may make for your case. While these are not exhaustive, the main three options are as follows:
- Sustain the agency’s action; finding that it was correct and that the application should be denied.
- Reverse the agency’s action; finding that agency acted incorrectly; OR
- Remand the agency’s action; sending the case back to the agency to evaluate it further. [4]
The DMAS hearing officer’s decision is the final step in the administrative appeals process.
However, if the applicant still does not agree with the outcome of the appeal, they may appeal to the Virginia Circuit Court within 30 days of the hearing officer’s decision. [5]
While a Medicaid denial process may come during a difficult time in an applicant’s life, knowing how to commence the appeals process should hopefully provide relief to those who should rightfully be receiving coverage.
[1] https://www.dmas.virginia.gov/appeals.
[2] One of the places an applicant may apply is through the Cover Virginia website located here.
[3] DMAS FAQ, https://www.dmas.virginia.gov/appeals.
[4] Id.
[5] Id.