Health & Benefits

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The Big Picture

Medicaid is a state and federal program that pays for medical costs for people with low income. Medicaid covers low-income…

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If your application for Medicaid is turned down, you can appeal and ask for a fair hearing. To learn more about the rules that DHS has to follow for Medicaid applications, you can read the Cash, SNAP, and Medical Policy Manual.

If you are appealing a Medicaid benefits decision, the first thing you need to do is be sure you appeal on time. If you don't, your appeal will be dismissed.

Generally, you must appeal a Medicaid benefits decision within 60 days of the date of the notice. If you want to appeal the Department of Human Services' (DHS) delay or failure to make a Medicaid decision, there is no time limit.

If the deadline falls on a weekend or a holiday, you have until the next weekday that isn't a weekend or a holiday to submit your appeal.

Remember that it is your duty to keep DHS informed of your address if you move. It is also your responsibility to check your mail every day. If DHS has proof that they mailed a notice to you and you did not receive it because you did not check your mail, then you could lose your right to appeal.

You can also start an appeal by writing this information on a blank piece of paper and signing and dating the paper:

• Your name,
• Your address,
• Your telephone number,
• Your DHS case number (the same number as the one on your DHS medical card),
• The date,
• That this appeal is about a problem with your Medicaid case, and
• The reason why you are appealing.

Keep a copy of your Notice of Appeal for yourself and mark it with the date you filed it.

You may be able to keep your Medicaid benefits during the appeal. For your Medicaid benefits to continue during your appeal, you must appeal before the Date of Change on the written notice or within 10 calendar days of the date of the notice. The Notice of Appeal form has a check-off to ask that your benefits continue. If you appeal by calling the Bureau of Assistance Hearings phone number, you can ask to continue receiving your benefits. Be sure to tell them if you want your benefits to continue during the appeal process.

Look over your case file to find out what issue relates to the appeal. If possible, meet with or speak to your DHS caseworker on the phone.

Verify that a pre-hearing conference has been scheduled. If not, talk to your DHS caseworker. Sometimes pre-hearing conferences are ignored or scheduled by phone.

Within 10 days after the appeal is filed, a pre-hearing conference should take place.

The pre-hearing conference is not the final hearing. At this conference, you can look at your case file. You will be able to discuss your case with your DHS caseworker and the caseworker's supervisor.

The decision in your case may be changed at this pre-hearing conference. DHS may agree with you, you might reach a compromise, or they will stick to their original position. Depending on what happens at the pre-hearing conference, you might be asked if you want to withdraw your appeal. If that happens to you, do not withdraw your appeal. Only withdraw if DHS agrees to make a change to your case that solves the problem. If you come to an agreement, you should be sure to get the agreement in writing before withdrawing your appeal.

You should begin preparing for your hearing as soon as you file your notice of appeal. It would be helpful to write down:

• The problem or issue you are appealing,
• The important events in the order that they happened,
• Why you think DHS is wrong, and
• Any incorrect information DHS used to decide your case.

If there are witnesses who can help your case, bring them to the hearing. You should also bring any paperwork that would help you. Witnesses are most helpful when you do not agree with DHS about something that was said or happened, and your witness was there.

You can give information or verifications to DHS at any time during the appeal process. DHS has to reconsider your eligibility based on the new information. A denied application or canceled case can be reopened. If you are told you have to file a new application, tell the supervisor that rule PM 01-07-08 allows you to turn in new documents any time during an appeal that was filed timely.

Asking for a continuance

If necessary, you can ask for your hearing to be pushed back to a later date. This is called a continuance. You do not have to show "good cause" or a valid reason for the first continuance. If you request another continuance, then you must show good cause. An example of a good cause is a family emergency.

If DHS does not approve your request at the pre-hearing stage, they will schedule a fair hearing. At the hearing, you will have the opportunity to present your case before a hearing officer, and DHS will then issue a written decision. At the hearing, you have the following rights:

• To be represented by a lawyer, friend, or relative,
• To bring in witnesses,
• To show documents supporting your case, such as medical records and your doctor's statements, and
• To have a reasonable accommodation, if needed, to participate.

The hearing will be held at the local DHS office or by telephone. There is no cost for a hearing. Someone who is not connected with your case will conduct the hearing. The people at the hearing will be:

• The hearing officer (by telephone),
• The caseworker and a supervisor,
• Witnesses, and
• You and your representative, if you have one.

The hearing might go like this:

• The hearing officer will explain the purpose of the hearing and will try to describe the problem.
• Everyone must swear to tell the truth.
• The hearing officer will ask the caseworker or supervisor to explain what happened, and they will submit all written notices.
• After each DHS person speaks, you may ask questions to that person.
• When DHS is done with their case, you may present your case. This is your chance to explain your side of the story as clearly as possible. Ask your witnesses questions so he or she can tell in his or her own words what happened. If you have papers to submit, tell the hearing officer what they are, give them to the hearing officer, and ask for copies back for yourself.
• After everyone has testified, ask the hearing officer to let you make a closing statement. Use this time to briefly explain again why you think DHS is wrong.
• The hearing officer will then make a decision about the appeal.

If you win your appeal, your Medicaid coverage will be retroactive to:

• the date that coverage would have started if your application had been approved, or
• the date your coverage would not have ended.

If the hearing officer rules against you or you disagree with their decision, you can file a lawsuit in an Illinois Circuit Court. You must file the lawsuit no later than 35 days from the date that the decision was sent to you. This process is very difficult, so you should talk to an attorney before starting it.

During the lawsuit, you or your lawyer will argue your case to the judge. The judge will then decide whether DHS and the hearing officer fairly looked at the facts and properly applied the law. The judge will not hear new evidence that was not presented before.

The judge can approve your claim, deny your claim, or send your case back to DHS for a new hearing.