How to File an Appeal If Your Medicaid Isn’t Renewed
Key takeaways:
Now that the COVID-19 public health emergency has ended, an estimated 8 million to 24 million Medicaid enrollees could lose their coverage. However, many will be disenrolled for procedural reasons and may still qualify for coverage.
If you can’t be reinstated within 90 days of termination, you can appeal the disenrollment decision by requesting a fair hearing. The process varies by state or territory. You may be able to expedite your hearing and a decision if losing Medicaid could endanger your life or health.
States and territories were advised to be prepared for an increased volume of fair hearing requests when Medicaid renewals resumed.
If you were disenrolled from Medicaid and believe you, your child, or someone else in your household still qualifies, you can challenge the decision. Generally, you can appeal a Medicaid eligibility decision by requesting a fair hearing.
Here’s how to appeal a Medicaid decision that resulted in you losing your coverage.
How are Medicaid renewals changing in 2023?
The U.S. Department of Health and Human Services declared a public health emergency (PHE) for COVID-19 in January 2020. The PHE was renewed a dozen times through February 2023.
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People who qualified for Medicaid during the COVID PHE were able to keep their insurance throughout the pandemic without having their eligibility reviewed. This ongoing eligibility applied to people in all states, Washington, D.C., and five U.S. territories. As part of the PHE provisions winding down, Medicaid continuous coverage ended on March 31, 2023.
The PHE ended on May 11, 2023 and, by June, most states had resumed their Medicaid and Children’s Health Insurance Program (CHIP) redetermination process. This is known as the “unwinding” of Medicaid. As a result of the unwinding, an estimated 8 million to 24 million Medicaid enrollees across the country could lose coverage.
However, many of those who are disenrolled will still be eligible for Medicaid or CHIP. They’ll lose coverage for procedural reasons such as:
Confusion around the redetermination process
Not reporting address and other contact information changes to their Medicaid agency
Failure to respond to information requests during the eligibility reviews
Paperwork errors, also known as churn
More than 1.5 million people had been disenrolled by June 22, 2023, according to analysis of early data from 25 states and Washington, D.C. by the Kaiser Family Foundation. This is an important benchmark to note because the unwinding will continue through summer 2024 in most states.
You can read specifics about Medicaid renewals resuming in your state or territory in our GoodRx Guide to Medicaid unwinding.
If I lose Medicaid coverage, how do I appeal the decision?
First, you should carefully read the letter you receive in the mail that notifies you that your Medicaid coverage is ending. If your address was not up to date with your Medicaid agency, you may not have received a letter. You may have discovered that you lost coverage while trying to use your Medicaid insurance.
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If your state has an online self-service portal, you can log in to check the status of your Medicaid. While you’re there, you can confirm and update your contact information.
If you have been disenrolled recently, there’s a chance you can submit a completed renewal form and have your Medicaid restored. If you lost coverage because you missed the renewal deadline, you can typically send your information within 90 days of the due date and have your case reconsidered. If you are approved, your insurance will be reinstated to the date you lost coverage. You also have the option to reapply.
If it’s been more than 90 days, you can appeal the non-renewal decision by requesting a fair hearing. Some states have extended the timeframe for fair hearing requests. All states will be required to report pending Medicaid fair hearings in monthly reports to the Centers for Medicare & Medicaid Services (CMS).
Texas, for example, allows 90 days or 120 days to request a fair hearing in writing, by phone, or by visiting a Texas Health and Human Services Commission local office. An expedited hearing can be granted for an individual who believes being without Medicaid will imperil life or health. A hearing can be conducted by phone or in person.
In 2022, the CMS advised states and territories to prepare for an increase in fair hearings when renewals resumed.
What are my options for health insurance while I’m uninsured?
If someone in your household is disenrolled, the person will be uninsured for a short time or longer while you wait for a resolution to your appeal. If you, your child, or another adult needs care right now and doesn't have insurance, free and low-cost services may be available in your area. If someone in your household depends on prescription medications, always check GoodRx for discounts that can make them affordable.
If you or your child are without coverage, even temporarily, you also have other health insurance options, such as:
Medicaid expansion programs: If you live in Washington, D.C. or a state that has expanded Medicaid, there may be an alternative health insurance program for you or your child that covers individuals from households that make slightly more than Medicaid and CHIP income eligibility limits. You should have been alerted to this option in your notice of termination.
Affordable Care Act (ACA) marketplace plan: You may be able to find an ACA health plan for $10 or less per month if you qualify for a premium subsidy. If you lose Medicaid coverage during the redetermination process, you can purchase a plan through the ACA marketplace during the unwinding special enrollment period from March 31, 2023 to July 31, 2024.
Employer plan: If you have a job, you may be able to get employer-sponsored health insurance. In most states, children can remain on a parent’s plan until age 26.
Student health plan: If you or your child are enrolled in a college or university, you may be eligible for a campus health plan.
Medicare: If you have a qualifying disability or condition — such as end-stage renal disease or ALS (amyotrophic lateral sclerosis), commonly referred to as Lou Gehrig’s disease — you can enroll in Medicare at any age.
Partner’s plan: If you have a spouse or domestic partner who has insurance, you may be able to join their plan during an open enrollment or special enrollment period.
Special plans: Short-term insurance can be a great choice if you anticipate that a better option, like job-based health insurance, will be available soon. You may also consider alternative and limited-benefit plans, such as fixed indemnity, accident, cost-sharing, and catastrophic insurance plans.
U.S. Department of Veterans Affairs (VA) benefits: If you are an active-duty service member or a veteran, you may qualify for TRICARE coverage or VA benefits and services.
The bottom line
If you, your child, or someone else in your household loses Medicaid or CHIP, you can appeal the decision by requesting a fair hearing.
The appeal process varies by state or territory. You may be able to expedite your hearing if being without Medicaid could worsen your condition or endanger your life. States and territories were advised to be prepared for an increased number of fair hearing requests as Medicaid unwinds.
If your appeal is unsuccessful, you may qualify for alternative options such as an Affordable Care Act marketplace plan, job-based health insurance, or Medicare.
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References
Administration for Strategic Preparedness & Response. (2020). Determination that a public health emergency exists.
Administration for Strategic Preparedness & Response. (2023). Renewal of determination that a public health emergency exists.
Centers for Medicare & Medicaid Services. (2022). Strategic approaches to support state fair hearings as states resume normal eligibility and enrollment operations after the COVID-19 PHE.
Centers for Medicare & Medicaid Services. (2023). Temporary special enrollment period (SEP) for consumers losing Medicaid or the Children’s Health Insurance Program (CHIP) coverage due to unwinding of the Medicaid continuous enrollment condition – Frequently asked questions (FAQ).
Kaiser Family Foundation. (2022). CHIP program name and type.
Maximus. (2023). Anticipate spike in ‘fair hearings’ that address eligibility decisions as states ramp Medicaid Unwinding efforts.
Texas Health and Human Services. (2010). Fair and fraud hearings handbook: 1200, notice.
Texas Health and Human Services. (2011). Fair and fraud hearings handbook: 1400, scheduling the hearing.
Tolbert, J., et al. (2023). 10 things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation.
U.S. Department of Veterans Affairs. (2022). VA & TRICARE information.
