(NARRATOR): Have your Medicaid services or programs been cut
or new requests denied?
Maybe your physical therapy hours have been reduced,
or maybe your request for new glasses was denied.
If so, you need to know about Medicaid Fair Hearings.
A Medicaid Fair Hearing is a process that lets
you fight against cuts or denials
of the Medicaid services that you need.
The outcome will decide which services you receive
so it’s important to take it seriously.
If you think a decision about your services is wrong,
you should ask for a hearing.
But the Fair Hearing process can be confusing.
So let’s try to break it down.
Medicaid managed care organizations (MCOs)
or state Medicaid agencies,
may sometimes cut or deny your services.
If they do, you should receive a letter -
called a Denial Notice.
It’s important to understand everything in the letter
so that you’re ready to advocate.
Let’s take a closer look!
There are four things that should be in the letter.
One: There should be a clear explanation
of what is changing or has been denied.
For example, maybe they are
decreasing your physical therapy services
from 3 days a week to 1.
Or, denying a request for a new prosthetic limb.
Two: There should also be a specific reason
why they made that decision.
If the letter just says that, "the service isn’t
medically necessary” and nothing else
- that’s not enough.
Three: The MCO or state Medicaid agency
also has to include which laws or rules
they say support their decision.
Four: It’s important to know that you may have
as little as 10 days after receiving the letter
to request a hearing so that your services
stay the same during the process.
They need to tell you what they’re doing,
why they’re doing it,
and how you can respond.
So, what about the hearing itself?
Your Fair hearing is a chance for you to explain
why you need the services they’re denying
or trying to take away.
So before the hearing,
make sure you gather plenty of evidence
to support your case.
Evidence might include receipts related to your medical care,
or notes from a doctor.
The hearing isn’t always in a courtroom
- it’s over the phone most of the time.
But it’s still a serious, confidential legal meeting.
There may be several people participating in the hearing,
including witnesses,
the MCO or state Medicaid agency representative,
and a hearing officer, who will listen to you
and make the final decision.
Make sure you explain your needs clearly and completely.
The services you’re fighting for impact your everyday life.
After the hearing,
the hearing officer will make a decision about your services.
A written decision will be sent to you sometime after the hearing.
They may disagree with you,
and your services can be cut or denied.
Or, they may agree with you,
and your services can be approved!
You deserve to have the services you need.
Medicaid Fair Hearings play an important role
in deciding what services you receive.
So make sure you’re ready to advocate!