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How to Challenge an NYC Medicaid Denial or Cut in Coverage
This page is for New York City applicants, and the families helping them, whose Medicaid application, home care hours or nursing-home coverage was denied, reduced or ended by the Human Resources Administration (HRA) or by a managed long-term care (MLTC) plan. It explains how to read the notice, which deadline applies to you, how to request and prepare for a fair hearing, and how a lost hearing is reviewed in court under CPLR Article 78.
Reviewed by Albert Goodwin, Esq. Last reviewed: 2026. Dollar figures and program rules change, often every January. Confirm current numbers against the latest HRA Medicaid Alert or New York State Department of Health GIS message before you rely on them.
What This Page Covers, and What It Does Not
This page deals with eligibility and coverage disputes, where the agency says you do not qualify or need less care than you claim. It does not cover accusations of fraud. If HRA or a prosecutor says you received benefits you were not entitled to, the process and the risks are different. See our pages on the administrative disqualification hearing and on allegations of misreporting separation for food stamps and Medicaid.
The Legal Framework
- Right to a hearing: Social Services Law § 22 gives anyone whose Medicaid is denied, reduced or discontinued the right to a fair hearing before the State. Federal Medicaid rules at 42 CFR Part 431, Subpart E, impose the same requirement.
- Hearing procedures: 18 NYCRR Part 358 sets the deadlines, the notice requirements, your right to see the case file, and the rules for aid continuing.
- Who runs the hearing: The Office of Administrative Hearings within the New York State Office of Temporary and Disability Assistance (OTDA) holds Medicaid hearings on behalf of the Department of Health. An Administrative Law Judge (ALJ) presides.
- Court review: A final hearing decision can be challenged in a proceeding under CPLR Article 78.
The name "fair hearing" can mislead people. It is a contested proceeding. HRA sends a trained representative to defend its decision, and the recording of the hearing becomes the only record a court will look at later.
Identify Which Medicaid Program Was Denied
The rules that decide your case depend on the category of Medicaid at issue. Many NYC denials go wrong because the applicant, or the agency, applied the wrong category's rules.
- MAGI Medicaid: This covers most adults under 65, children, pregnant people and parents. Eligibility is based on income only. There is no resource or asset test for MAGI Medicaid. If a notice denies MAGI coverage for "excess resources," that is an error worth challenging. Many MAGI cases are handled through NY State of Health rather than HRA, and the notice will say which agency acted.
- Non-MAGI community Medicaid (aged, blind or disabled): People 65 and older, people who are blind or disabled, and people with Medicare generally fall here. This category has both an income limit and a resource limit. For 2025 the resource limit for an individual was $32,396 and for a couple $43,781. The limit is adjusted each January, so check the current GIS message. Excess income can often be handled through a spend-down or a pooled income trust.
- Home care and MLTC: Personal care, home attendant services and MLTC enrollment require both financial eligibility and a needs assessment. Since 2022, initial assessments for community-based long-term care have been conducted by the New York Independent Assessor Program (NYIAP), which replaced the Conflict-Free Evaluation and Enrollment Center (CFEEC). Disputes over hours or enrollment are usually about the assessment, not money.
- Institutional (nursing home) Medicaid: Chronic-care Medicaid applies a 60-month look-back on transfers of assets. Uncompensated transfers in that period produce a penalty period calculated by dividing the transferred amount by the regional monthly nursing-home rate published by DOH.
A note on the community look-back: the 2020 State budget amended Social Services Law § 366 to add a 30-month look-back for community-based long-term care, including home care and MLTC. Implementation has been repeatedly delayed. As of our last review, it had not taken effect, and transfers did not cause a penalty for community home care. Check the current HRA Medicaid Alerts before you make or rely on any transfer, because this can change.
How to Read Your Notice of Decision
Most people skim the notice for the word "denied" and stop reading. The notice contains the information that controls your deadlines and your argument. Look for these items, generally in this order:
- Notice date: Usually near the top. Your 60-day hearing deadline runs from this date, not from the day the letter arrived.
- Effective date: For a reduction or discontinuance, the notice states the date the change takes effect. To keep coverage during the appeal, your hearing request must reach OTDA before this date. That is typically 10 days after the notice date.
- Case number and client ID: Copy these exactly into your hearing request.
- The action taken: Denial of an application, discontinuance, reduction of hours, imposition of a transfer penalty, or a change in your monthly spend-down.
- The stated reason: This is often a short phrase or code, such as "resources exceed the allowable limit" or "failure to provide requested documentation."
- Regulations cited: The notice must cite the law or regulation it relies on. A missing, vague or mismatched citation can itself be grounds to reverse the decision for inadequate notice under 18 NYCRR § 358-2.2.
- Budget or calculation page: In income and resource cases, HRA may attach a budget showing the figures it used. Compare every line to your own records. Errors here are common.
- Your rights section: Usually on the back. It lists the OTDA phone line, fax number and mailing address, and explains the right to a local agency conference.
A notice that fails to explain the reason clearly, or that gives you less time than the law requires, is a separate issue to raise at the hearing alongside your argument on eligibility.
Common Reasons for Denial and Where the Dispute Usually Lies
| Reason on the notice | Where the dispute usually lies |
|---|---|
| Excess resources | Only applies to non-MAGI and institutional Medicaid. Common issues: a joint bank account counted in full when the other owner contributed the money; an irrevocable trust counted as available when the trustee has no power to return principal to the applicant; a home or co-op counted when it is exempt; or a retirement account counted when it is in periodic payout status. |
| Excess income | Whether income was budgeted correctly, whether an exclusion applies, whether a spousal income allowance was applied, and whether the excess can be placed in a pooled income trust under Social Services Law § 366(2)(b)(2)(iii) and 42 U.S.C. § 1396p(d)(4)(C). |
| Transfer penalty | Whether a transfer was actually for fair value, whether the penalty used the correct regional rate and start date, and whether an exempt transfer applies under Social Services Law § 366(5) and 42 U.S.C. § 1396p(c)(2). Exempt transfers include transfers to a spouse, to a blind or disabled child, of the home to a caregiver child who lived there and provided care for two years, and of the home to a sibling with an equity interest who lived there for a year. |
| Failure to provide documentation | Whether the documents were submitted and lost, whether the request was clear and gave enough time, and whether HRA demanded items the regulations do not require. |
| Reduced home care hours or MLTC denial | Whether the assessment reflects your actual needs, including nighttime needs, cognitive impairment and safety risks, and whether the plan or agency explained why your condition supposedly improved. |
| Spousal refusal issues | Whether HRA properly processed a spousal refusal under Social Services Law § 366(3)(a). A community spouse's refusal to contribute generally does not bar the applicant's eligibility, though the agency may later seek support from the refusing spouse. |
| Residency or immigration status | Whether the applicant is a New York resident and holds a status that qualifies for full coverage. New York covers some immigrant groups that federal Medicaid does not. |
Deadlines
- 60 days to request a fair hearing: For an HRA Medicaid decision, you have 60 days from the notice date under Social Services Law § 22(4) and 18 NYCRR § 358-3.5.
- Before the effective date for aid continuing: If existing coverage is being reduced or ended, request the hearing before the effective date on the notice, usually within 10 days, and ask for aid continuing (18 NYCRR § 358-3.6). Your benefits then stay in place until the hearing decision. If you lose, the agency may seek to recover the cost of services provided during that time. Aid continuing is not available on a first-time application denial.
- MLTC plan decisions: If your MLTC plan, rather than HRA, reduces or denies services, you generally must first file an internal plan appeal within 60 days of the plan's notice. You can then request a fair hearing within 120 days of the plan's final adverse determination (42 CFR § 438.408). Ask the plan for aid continuing when you file the internal appeal. For medical-necessity disputes, an external appeal through the Department of Financial Services may also be available.
- Expedited hearings: If waiting for a standard hearing could seriously jeopardize your health or ability to function, you can ask OTDA for an expedited hearing under 42 CFR § 431.224.
- Agency conferences do not stop the clock: You can ask HRA for a local agency conference to try to fix the problem informally. That request does not extend the hearing deadline. File the hearing request anyway.
- Four months for Article 78: A court challenge must be filed within four months after the hearing decision becomes final and binding (CPLR 217(1)).
Missing the 60-day deadline usually means filing a new application, which can cost months of coverage. A late request may be accepted only in limited circumstances, so treat the deadline as fixed.
How to Request the Fair Hearing
You can request a hearing in four ways:
- Online: Through OTDA at otda.ny.gov/oah. You receive a confirmation, which is the best proof of a timely request.
- By phone: OTDA's statewide fair hearing line, 800-342-3334. Write down the date, time and the name of the person you spoke with.
- By fax: To the number on your notice. Keep the transmission confirmation sheet.
- By mail: To the address on your notice. Use certified mail with return receipt.
Sample Hearing Request Script
Whether you call or write, the request can be short. Something like this is enough:
"My name is [name]. I am requesting a fair hearing to appeal a Medicaid decision by the New York City Human Resources Administration. My case number is [number] and my client ID is [ID]. The notice is dated [date]. The agency [denied my application / reduced my home care hours / discontinued my Medicaid / imposed a transfer penalty]. I disagree with this decision. [If coverage is being reduced or ended:] I am requesting aid continuing. [If applicable:] My health would be at serious risk if this hearing is not expedited, and I am asking for an expedited hearing. I also request a copy of my case file and all documents the agency will use at the hearing."
You do not need to argue your case in the request. You only need to be clear about which decision you are appealing. OTDA then mails a Notice of Hearing with the date and instructions. Most NYC Medicaid hearings are now held by telephone or video.
Get the Agency's File and Evidence Packet
Under 18 NYCRR § 358-3.7, you have the right to examine your case record and to receive copies of the documents the agency plans to use at the hearing. Ask for them in writing as soon as you request the hearing. If the request is made close to the hearing date, the agency may provide the documents at the hearing itself, which leaves you little time to respond.
When the file arrives, compare it against what you submitted. Look for documents that are missing, figures that differ from your statements, and notes showing what the caseworker relied on. A gap between what you sent and what is in the file is often the whole case in a documentation denial.
Documents That Usually Matter
| Denial category | Documents that usually matter |
|---|---|
| Excess resources | Bank and brokerage statements, deeds and co-op share certificates, trust instruments, retirement account payout records, and records showing who deposited the money in a joint account. |
| Excess income | Social Security and pension award letters, the pooled-trust joinder agreement and proof of monthly deposits, and records of excluded income. |
| Transfer penalty | Contracts, appraisals, closing statements, caregiver agreements and payment records showing fair value. For an exempt transfer: proof of the child's disability, or proof the caregiver child or sibling lived in the home and provided care for the required period. |
| Failure to document | Copies of everything previously submitted, with fax confirmations, upload receipts or certified-mail receipts. |
| Home care or MLTC | Physician letters describing specific needs, a log of daily care tasks and nighttime needs, prior assessments, and the plan's or assessor's notes. |
| Residency or immigration | Lease, utility bills, government mail, and immigration documents. |
Sample Exhibit Index
Submit your evidence in a tabbed packet with an index like the one below, and send a copy to OTDA and to the HRA representative before the hearing if the Notice of Hearing allows it. An organized packet makes it easy for the ALJ to follow your argument and makes the record clear if a court reviews it later.
- Exhibit A: Notice of Decision dated [date]
- Exhibit B: Hearing request confirmation
- Exhibit C: Written statement of the applicant's position, one to two pages
- Exhibit D: Proof of documents previously submitted to HRA, with dates
- Exhibit E: Financial records supporting the correct calculation
- Exhibit F: Trust, deed or transfer documents, if relevant
- Exhibit G: Medical evidence, if needs or disability are at issue
- Exhibit H: Copies of prior fair hearing decisions relied on
- Exhibit I: Statutes and regulations cited
Using Prior Fair Hearing Decisions
ALJs are not strictly bound by earlier hearing decisions, but a prior decision with similar facts is persuasive, especially on how a regulation has been applied. OTDA posts redacted fair hearing decisions on its website, and legal services organizations maintain searchable collections of past Medicaid decisions.
To use them well:
- Search by the regulation cited in your notice and by key facts, such as "joint account" or "caregiver child."
- Prefer recent decisions. Rules and agency policy change, and an old decision may rest on a superseded rule.
- Cite the fair hearing number and date, and attach a copy. Do not rely on a summary you cannot attach.
- Explain in one or two sentences why the facts match yours.
What Happens at the Hearing
The ALJ opens the record and HRA's representative explains the agency's decision and offers its evidence packet. You then present your documents and witnesses, and each side may question the other's witnesses. In an MLTC case, the plan presents its position instead of or alongside HRA. The hearing is recorded.
Raise every issue at this stage, including defects in the notice. Put every document you rely on into the record. If HRA introduces something you have not seen, ask for time to respond or ask that the record be held open. The ALJ usually reserves decision and issues a written ruling. Under 18 NYCRR § 358-6.4 and federal rules, a Medicaid decision is generally due within 90 days of the hearing request, absent delays you requested.
If you win, the decision directs HRA or the plan to take corrective action, such as approving the application, restoring hours or recalculating a budget. If the agency does not comply within a reasonable time, you can file a compliance complaint with OTDA.
Article 78 Review of a Lost Hearing
If the hearing decision goes against you, the next step is an Article 78 proceeding. Several points about how these cases work in New York are often misunderstood:
- Where to file: The petition is filed in New York State Supreme Court. Under CPLR 506(b), venue lies in a county within the judicial district where the determination was made, where the material events took place, or where the respondent's principal office is located. For an NYC resident, that is often the county where the applicant lives, such as New York County Supreme Court for a Manhattan case.
- Who the respondents are: Typically the State Commissioner of Health, whose department issues the final Medicaid decision, and the Commissioner of the New York City Department of Social Services, which runs HRA. The Attorney General must also be served.
- The standard of review: When the challenge is that the decision is not supported by the evidence, the question is whether it rests on "substantial evidence" in the hearing record (CPLR 7803(4)). When the challenge is that the agency misapplied the law or acted arbitrarily, CPLR 7803(3) applies.
- Transfer to the Appellate Division: If the petition raises a substantial-evidence question, Supreme Court does not decide it. Under CPLR 7804(g), the court transfers the case to the Appellate Division. For Manhattan and Bronx cases that is the First Department. For Brooklyn, Queens and Staten Island it is the Second Department. Purely legal challenges may be decided by Supreme Court itself.
- The record is closed: The court reviews the hearing record. New evidence generally cannot be added. A document you did not submit at the hearing usually cannot help you in court.
- Deadline: Four months from when the decision became final (CPLR 217(1)).
If the court rules for you, it typically annuls the decision and sends the matter back to the agency to act consistently with the ruling.
A Typical Timeline
| When | What happens |
|---|---|
| Day 0 | HRA or the MLTC plan issues the notice. |
| Before the effective date, usually within 10 days | Request the hearing (or internal plan appeal) with aid continuing if coverage is being reduced or ended. |
| At the time of the request | Request the case file and evidence packet under 18 NYCRR § 358-3.7. |
| Within 60 days | Last day to request a hearing on an HRA decision. |
| Weeks before the hearing | Review the file, gather documents, research prior decisions, prepare the exhibit packet. |
| Hearing date | Present the case and build the record. |
| Generally within 90 days of the request | OTDA issues the written decision. |
| Within 4 months of a final adverse decision | File an Article 78 petition if needed. |
Timing varies with adjournments, expedited requests and how quickly HRA produces its file.
When You Need a Lawyer, and When You May Not
Some denials are simple to fix. If HRA lost a document you can prove you sent, a clear hearing request and a copy of your fax confirmation may be all you need. Free help is also available from legal services organizations in New York City, and their hotlines can be a good first call for MAGI denials and smaller disputes.
A private attorney is more useful when the stakes or the legal questions are larger: a nursing-home denial with months of private-pay costs at issue, a transfer penalty, a trust the agency refuses to recognize, a spousal refusal, a home care case with substantial hours at stake, or a hearing you already lost. In those cases the hearing record decides whether a court appeal is even possible, and gaps left at the hearing usually cannot be filled later.
We can review your notice, calendar the deadlines, request the case file, research on-point hearing decisions, prepare the exhibit packet and represent you at the hearing and in any Article 78 proceeding.
Frequently Asked Questions
How long do I have to request a NYC Medicaid fair hearing?
Generally 60 days from the date on the notice for an HRA decision. For an MLTC plan decision, you usually file an internal plan appeal first, then have 120 days from the plan's final decision to request a hearing.
Can I keep my Medicaid or home care during the appeal?
Yes, if existing coverage is being reduced or ended and you request the hearing before the effective date on the notice and ask for aid continuing. It does not apply to a first-time application denial.
Does MAGI Medicaid count my savings?
No. MAGI Medicaid has no asset test. A resource limit applies only to non-MAGI categories, such as people 65 and older or people with disabilities, and to nursing-home Medicaid.
Is there a look-back for home care in New York?
A 30-month look-back for community-based long-term care was enacted in 2020 but, as of our last review, had not been implemented. Nursing-home Medicaid has a 60-month look-back. Check current HRA guidance before making transfers.
What if I miss the 60-day deadline?
A late request is accepted only in limited circumstances. In most cases you will need to file a new application.
What happens if I lose the fair hearing?
You can file an Article 78 proceeding in Supreme Court within four months. If the petition challenges whether the decision was supported by substantial evidence, the case is transferred to the Appellate Division under CPLR 7804(g).
Related Medicaid and Planning Pages
- New York City Medicaid attorney: an overview of our Medicaid eligibility and planning work.
- Benefits of a special needs trust: how supplemental needs and pooled trusts preserve eligibility.
- Asset protection and moving assets to one spouse in New York: spousal planning that affects nursing-home eligibility.
- Advanced New York estate planning techniques: including irrevocable trusts used in Medicaid planning.
- Advance directives in New York: powers of attorney and health care proxies that let a family member request a hearing and handle a Medicaid case.
Talk to Us About Your Notice
If you received a notice denying, reducing or ending Medicaid or home care in New York City, the deadline is already running. Contact us so we can review the notice and calendar the dates. Call 212-233-1233 or email [email protected]. You can learn more about Albert Goodwin.
This page provides general information about New York law and is not legal advice for any specific situation.
About the Author
Albert Goodwin Esq. is a licensed New York attorney with over 18 years of courtroom experience. His extensive knowledge and experience make him well-qualified to write authoritative articles on a wide range of legal topics. He can be reached at 212-233-1233 or [email protected].
