Navigating Medicaid Denials and Appeals in New York

As a New York elder law attorney, we understand that navigating the Medicaid long-term care denials and appeals process can be a stressful process for seniors and their families. This guide will walk you through the steps to successfully appeal a Medicaid decision in New York, ensuring that you have the support and resources you need.

Step 1: Receiving the Notice of Decision

After submitting your Medicaid long-term care application, the local Department of Social Services (DSS) or the New York State of Health (NYSOH) will review your application and send you a written notice of their decision. The notice of decision should contain clear information about the outcome of your Medicaid application, the specific reasons for denial (if applicable), and the steps to take if you wish to appeal the decision. If your application is denied or you disagree with the decision, you have the right to request a fair hearing within 60 days of the date on the notice.

Step 2: Requesting a Fair Hearing

A fair hearing is a formal administrative proceeding where an individual can challenge a government agency’s decision, such as a Medicaid denial, before an Administrative Law Judge (ALJ). A fair hearing is important because it provides individuals who have been denied Medicaid benefits or disagree with a decision the opportunity to present their case before an impartial ALJ. This process ensures that applicants have a chance to advocate for themselves and potentially secure the healthcare benefits they need and deserve. To request a fair hearing, you can:

• Call the New York State Office of Temporary and Disability Assistance (OTDA) at 1-800-342-3334
• Submit an online request through the OTDA website
• Mail or fax a written request to the OTDA, following the instructions on your notice of decision

Step 3: Preparing for Your Fair Hearing

Preparing for your fair hearing is crucial because it increases your chances of successfully appealing the Medicaid decision. By gathering relevant documents and organizing your arguments, you can present a compelling case to the ALJ, demonstrating your eligibility for the benefits you need. Such documents may include:

• Medical records
• Financial statements
• Letters from healthcare providers
• Any other documentation that demonstrates your eligibility for Medicaid

Step 4: Attending the Fair Hearing

At the fair hearing, you will have the chance to present your case to the ALJ, who will listen to both sides and review the evidence before making a decision. You can bring a representative, such as a lawyer, family member, or friend, to help present your case. Please note, however, that if you wish to have someone who is not a lawyer represent you, you must first file written authorization from the Office of Administrative Hearings (OAH).

Step 5: Receiving the ALJ’s Decision

After the hearing, you will receive a written decision from the ALJ. If the decision is in your favor, the DSS or NYSOH will be required to correct their decision and provide you with the appropriate Medicaid benefits. If you receive an unfavorable decision after your fair hearing, you still have options to pursue. One possibility is to request a reconsideration or reopening of the fair hearing decision within 60 days if you can present new evidence or show that a mistake was made. Additionally, you can seek judicial review by filing an Article 78 proceeding in New York State Supreme Court within four months of the unfavorable decision. This process involves presenting your case to a judge who will review the fairness and legality of the administrative decision. Keep in mind that an experienced attorney can provide valuable guidance and representation throughout these processes, helping you navigate your options and fight for the Medicaid benefits you need.

Conclusion

Navigating the Medicaid appeals process can be challenging, but you don’t have to do it alone. An experienced New York Medicaid attorney can guide you through the process, providing valuable advice and representation to help you secure the benefits you deserve. Contact us at the Chamberlain Law Firm today for a consultation and let us help you on your journey to access the Medicaid long-term services that you need.