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Dealing with Denials or Reductions of Medicaid Services

I’ve heard from my child’s service provider that my child’s Medicaid services are being denied or reduced. Am I supposed to get something in writing from my child’s Medicaid managed care organization (MCO) about this?

Yes, according to state and federal Medicaid law the MCO must send a written notice of a denial or reduction in services to you and your child.

I’ve received a denial letter in the mail from the MCO about a denial or reduction in my child’s services. Do I have the right to challenge the MCO’s denial or reduction decision?

Yes, you have the right to challenge the MCO’s decision to deny or reduce your child’s services. You can request an appeal or a Medicaid fair hearing.

What’s the difference between an appeal and a Medicaid fair hearing?

An appeal is a process within the MCO where another doctor (not involved with the initial denial or reduction decision) reviews the decision to determine whether that denial or reduction decision is correct. This is also known as an “internal appeal.” In contrast, a Medicaid fair hearing is an administrative process where an impartial hearings officer in the legal division of the Texas Health and Human Services Commission (THHSC) will hear evidence from both sides (frequently over the phone on a scheduled date) and make a decision about whether the MCO’s determination to deny or reduce services was correct and based on Medicaid policy.

If my child was previously receiving the service that is now being denied or reduced, can my child continue to receive that service during an appeal or Medicaid fair hearing

Typically, yes. If an appeal or Medicaid fair hearing is requested within 10 days of the proposed date of denial or reduction, or the date of the denial letter, the MCO must continue to authorize services at the pre-denial or reduction level. This is called “continuation of services” pending the outcome of the appeal or fair hearing.

What happens to my child’s services if I don’t appeal within 10 days of the proposed action date or the date of the denial letter? Do I lose the right to an appeal or Medicaid fair hearing?

 If you miss the 10-day deadline to maintain the continuation of services, your child’s services will be denied or reduced in accordance with the denial letter. However, you can still ask for an appeal or Medicaid fair hearing within 90 days of the proposed action date or date of the denial letter.

I’ve asked for an appeal or Medicaid fair hearing, but what do I do next?

You don’t have to go it alone. While we don’t assist with the internal appeal process at the MCO, we can still provide advice on what to do during that process. Also, although the Medicaid fair hearing process is designed to be informal, it can be intimidating. Disability Rights Texas (DRTx) may be able to help. If our attorneys have the resources, they can investigate your child’s case and may be able to represent your child at a Medicaid fair hearing. To learn more and to open a case file for your child at DRTx, please call our intake line at 1-800-252-9108.

Click the link below for the full pdf version of this information, from Disability Rights Texas.