I have been denied Medicaid coverage; what do I do now?

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It can be very confusing and/or frustrating when a Medicaid application has been denied or benefits terminated.  Steps need to be taken to preserve your rights.

The Medicaid applicant/recipient (or representative) needs to request an administrative hearing within forty-five (45) days from the date of the denial/termination notice.  To request a hearing, you must complete an Administrative Hearing Request form (MSC 0443) and return it to the Department of Human Services (DHS) or Oregon Health Authority (OHA).  The form can be obtained online, or you can contact the local office for help with the hearing request.

If the notice is regarding termination of benefits and you want the Medicaid benefits to continue while you wait for the hearing, you need to request that benefits stay the same by checking a box on the hearing request form.  You must make this request within ten (10) days of the notice.  If you keep receiving benefits pending the hearing but lose at the hearing, you must pay back the benefits received during that waiting period that you were not entitled to.  However, this can still be a benefit because the Medicaid reimbursement rate is less than the private pay rate.

Prior to the hearing, a pre-hearing phone conference will be scheduled with a DHS representative in an effort to resolve the issue(s).

Hearings are held by the Office of Administrative Hearings, which is independent from DHS or OHA.  An Administrative Law Judge (ALJ) will conduct the hearing.  Usually the hearing is by phone.  The Medicaid applicant/recipient may be at the local DHS branch or another location if that is more convenient.  You can have an attorney represent you at the hearing.  At the hearing, you can explain why you disagree with the decision, and have the right to have witnesses testify.

If you do not ask for a hearing on time, withdraw your request for the hearing, or miss your hearing, you may lose your right to the hearing.  The notice will become final by default.

Active duty service members have a right to delay the proceedings under federal law.  Contact the Oregon State Bar, Oregon Military Department, or the nearest legal assistance office for more information.

Finally, if you receive a notice of planned action terminating Medicaid benefits because you no longer qualify under Activities of Daily Living or Service Priority Rules, you should immediately request a reassessment by another staff member.

An experienced Elder Law attorney can help you to understand your rights to request an Administrative Hearing and answer your questions regarding Medicaid eligibility rules and planning options. Contact the Elder Law attorneys with the Law Offices of Nay & Friedenberg LLC in Portland, Oregon at (503) 245-0894 to set an appointment.

If you would like to learn more about Medicaid planning options, click here to receive our FREE Legal/Financial Planning Guide.