KPCB Edge — Keep Pushing Costs Back
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Module 5 of 6

Keeping your coverage

Lesson 2 of 2 in this module

Lesson 13 of 140% of the course done

Lesson 13

If you're denied or cut off

⏱ 2 min

Key points

  • Every denial or cutoff notice must say why and explain how to ask for a fair hearing.
  • States can give you up to 90 days to ask for a hearing; check your notice for the exact deadline.
  • If you already have Medicaid and ask for a hearing before the change date, your coverage usually continues.
  • If you don't qualify, the state sends your information to the Marketplace.

Being denied or cut off isn't always the final word. Mistakes happen, especially with income and household details, and you have the right to challenge a decision.

Read the notice

The notice has to give the specific reason for the decision and explain your right to a fair hearing. Sometimes the reason is a missing document or wrong income figure, and you can fix it by sending the right information. Call the agency first if the reason looks like a simple mistake.

Ask for a fair hearing

A fair hearing is a review by someone at the state who wasn't part of the original decision. You can explain your situation and bring proof. Federal rules let states set the deadline to ask, but it can't be more than 90 days from the date the notice was mailed, so check your notice for your state's exact date.

Keep your coverage during the appeal

If you already have Medicaid and the state plans to end or cut it, you should get a notice at least 10 days before the change. If you ask for a hearing before the change date, the state generally has to keep your coverage until the hearing decision. If you lose the hearing, the state may try to recover what it paid for that care, so ask your legal aid office whether to request continued coverage.

Legal aid offices help with Medicaid appeals for free. Find yours at LawHelp.org.

If Medicaid isn't the answer

When Medicaid denies you or ends your coverage, your state usually sends your information to the Marketplace. You may be able to buy a Marketplace plan with help paying for it, and you don't have to wait for them to contact you. Losing Medicaid gives you a special enrollment period, so you can sign up outside open enrollment.

Quick check

Your notice says your Medicaid ends on the 30th. You think it's a mistake. When should you ask for a hearing to keep your coverage during the appeal?

Sources: 42 CFR 431 subpart E, fair hearings, eCFR; If you lose or are denied Medicaid, HealthCare.gov.