State Fair Hearing (Medicaid)
After exhausting Medicaid MCO internal appeal, beneficiaries have the right to an Administrative Law Judge hearing at the state Medicaid agency. The state hearing officer can overrule the MCO.
What it is
A State Fair Hearing is an evidentiary hearing conducted by the state Medicaid agency (or its delegated administrative law tribunal) after the beneficiary has exhausted the MCO's internal appeal. The hearing officer (typically an ALJ) reviews the record, takes testimony from the beneficiary, the MCO, and any clinical experts, and issues a binding decision applying state and federal Medicaid law.
Who can use it
Medicaid beneficiaries (or their authorised representatives) who have exhausted MCO internal appeal and want an independent review.
When to use it
After receiving the MCO's final internal appeal decision. Federal floor: 120 days from the MCO decision. Many states allow concurrent state-fair-hearing and continued-benefits while the appeal is pending.
Steps
- Verify MCO internal exhaustion. State Fair Hearing is available AFTER the MCO has issued its final appeal decision (or after the MCO has missed its deadline). Most states require internal exhaustion.
- Request the hearing in writing. File with the state Medicaid agency — usually the agency's fair-hearing unit. State the basis for the appeal and request continued benefits if you want services to continue pending the hearing.
- Receive notice of hearing. State has 90 days from the request to schedule and hold the hearing in most states.
- Attend the hearing. Bring the chart, denial notices, internal appeal correspondence, and any clinical expert testimony. Many states allow telephone or videoconference hearings.
- Receive the decision. Hearing officer issues a written decision. If favorable, the MCO must comply. If adverse, judicial review is sometimes available.
Key deadlines
| Requirement | Deadline |
|---|---|
| Time to request State Fair Hearing | 120 days from MCO's final appeal decision (federal floor) |
| State decision timeline | 90 days for standard, 3 working days for expedited (varies by state) |
Frequently asked questions
What is state fair hearing (medicaid)?
A State Fair Hearing is an evidentiary hearing conducted by the state Medicaid agency (or its delegated administrative law tribunal) after the beneficiary has exhausted the MCO's internal appeal. The hearing officer (typically an ALJ) reviews the record, takes testimony from the beneficiary, the MCO, and any clinical experts, and issues a binding decision applying state and federal Medicaid law.
Who can use state fair hearing (medicaid)?
Medicaid beneficiaries (or their authorised representatives) who have exhausted MCO internal appeal and want an independent review.
When should I use state fair hearing (medicaid)?
After receiving the MCO's final internal appeal decision. Federal floor: 120 days from the MCO decision. Many states allow concurrent state-fair-hearing and continued-benefits while the appeal is pending.
Time to request State Fair Hearing — State Fair Hearing (Medicaid)?
120 days from MCO's final appeal decision (federal floor)
State decision timeline — State Fair Hearing (Medicaid)?
90 days for standard, 3 working days for expedited (varies by state)
Related
- 42 CFR 438 Subpart FThe federal floor for Medicaid managed care appeals. Beneficiaries get internal plan appeal + State
- Expedited (urgent) appealWhen standard appeal timelines would jeopardise life, health, or function. Federal law mandates 72-h
- External review (IRO)Independent Review Organization (IRO) review — a binding decision by an outside organization after i
- Federal IDR (No Surprises Act dispute resolution)Federal Independent Dispute Resolution for OUT-OF-NETWORK provider payment disputes after the No Sur
- Grievance (vs appeal)A grievance is a complaint about plan conduct — service, access, quality — that does NOT involve a c
Sources
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