Medicaid Appeals and Eligibility Rules Regarding Obtaining Health Care Coverage

Part 4, Chapter 13: Specialized Situations: Programs for Children and Adults with Disabilities and Special Health Care Needs Page 5

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Medicaid Appeals and Eligibility Rules

If you or a family member are unable to obtain needed care because your application for Medicaid has been rejected, and you think the application should have been approved under the existing rules of your state, it's important to make use of the Medicaid appeals process as soon as possible. Although the appeals system differs from state to state, the process generally includes an opportunity to appeal to a neutral hearing officer. While an appeal may result in a decision to grant Medicaid benefits, there is no guarantee of success.

There are a number of helpful booklets available on the issue of Medicaid appeals (See Appendix B). If you need more specific advice about a Medicaid appeal, the local Legal Services Office may also be able to help. You can locate the nearest office by calling the National Legal Aid and Defender Association (See Appendix B).

The local Bar Association may be able to provide information on the nearest Legal Services Office, as well. The Bar Association may also be able to refer you to the local office of the Protection and Advocacy Service, which may be particularly helpful on Medicaid eligibility issues or claim denials if the situation involves a child with a disability. There are also private organizations, including a number of disability law centers, that can provide help and advice with Medicaid-related issues (See Appendix B).

If you are considering applying for Medicaid for yourself or a family member, and there are assets that may affect eligibility, you should be aware that there are a number of laws that may relate to such assets. Thus, it's important to review your situation carefully with an attorney or with an agency such as the Protection and Advocacy Service or Legal Services before making any decisions about assets.

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