A Guide to the Medicaid Appeals Process Prepared by: MaryBeth Musumeci Kaiser Commission on Medicaid and the Uninsured The Henry J. Kaiser Family Foundation

Table of Contents
Executive Summary ...................................................................................................................................... 1
Introduction .................................................................................................................................................. 5
Constitutional Requirements of the Medicaid Appeals Process: Notice and Hearing.............................. 5
Adequate Notice of State Agency Actions ................................................................................................... 7
Hearing Requests and Continuing Benefits Pending Appeal .................................................................... 10
State Agency Hearing Process and Decisions ............................................................................................ 11
Medicaid Managed Care Appeals Process ................................................................................................. 14
MCO Notices of Action ............................................................................................................................ 16
MCO Appeal Requests and Continued Benefits Pending Appeal ............................................................ 18
MCO Appeals Process and Decisions ....................................................................................................... 20
State Fair Hearing Requests by MCO Enrollees ....................................................................................... 21
Looking Ahead ............................................................................................................................................ 25