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What do you do if your application for Medicaid long-term care benefits is denied by the Alabama Medicaid Agency?

Author: Brenton McWilliams

What do you do if your application for Medicaid long-term care benefits is denied by the Alabama Medicaid Agency?

If you apply for Medicaid and are denied Medicaid benefits, you may appeal the eligibility determination by filing an appeal with the Alabama Medicaid Agency within 60 days from the date of the determination.

After sending in an application for long-term care benefits to the Alabama Medicaid Agency, the applicant will receive an award letter. The award letter explains the decision made on the application including whether the applicant will receive benefits, when the applicant will begin receiving benefits, whether there is a transfer penalty imposed on the applicant as a result of an uncompensated transfer made during the lookback period, and any other limitations on benefits. If you disagree with the Alabama Medicaid Agency’s determination, you are allowed to appeal the decision through what’s generally referred to as a fair hearing.

The Appeal Procedure – Fair Hearing

The appeal must be in writing and filed with the Alabama Medicaid Agency within 60 days of the agency’s initial determination. The appeal must be filed on time or the agency will not grant a hearing.

The applicant making an appeal with a request for a fair hearing has a choice as to how the fair hearing will be conducted. The fair hearing can be an in-person hearing in front of an administrative law judge or a review hearing based solely on written evidentiary submissions from both sides.

The in-person fair hearing will be held before an administrative law judge. Both the applicant and the Alabama Medicaid Agency are given the opportunity to present and question witnesses at the hearing. Witnesses may be subpoenaed to attend the hearing. A record of the hearing will be created. Following the hearing, the administrative law judge will issue a written decision on the appeal. The administrative law judge’s opinion will be forwarded on to the Alabama Medicaid Agency Commissioner who will make the final decision on the appeal. The Alabama Medicaid Agency Commissioner is not bound by the administrative law judge’s decision and may modify, accept or reject the administrative law judge’s decision. Following the decision of the Alabama Medicaid Agency Commissioner, the applicant may petition for judicial review of the decision by filing a timely notice of appeal in the appropriate circuit court.

Important Timeframe for Individuals Already Receiving Medicaid Benefits

The Alabama Medicaid Agency requires recipients currently receiving Medicaid benefits to file an annual recertification to continue receiving benefits. If the Alabama Medicaid Agency takes some adverse action based on the recertification such as discontinuing benefits, suspending benefits, or lowering the amount of benefits provided, the appeal must be made according to the process discussed above. However, if the appeal is filed within 10 days of notice of the adverse action, the Medicaid recipient will continue to receive benefits at the status quo prior to the adverse action.

This article is for information purposes only and is current as of August 22, 2019. If you are considering filing an appeal from a decision of the Alabama Medicaid Agency, you should consult with an elder law attorney as soon as possible. As with appeals of any kind, the required procedure can be extremely technical and failure to follow the required procedure can result in the loss of your right to appeal. If you would like representation on a Medicaid appeal or if you have other elder law or elder care questions, please call me direct at (251) 215-9275 to set up an appointment or fill out a form on the contact page.