How To Challenge a Denial of NYC Medicaid

When New York City Medicaid denies your application or terminates your existing coverage, you have the right to fight that decision. The first step is to file a request for a fair hearing — an administrative trial conducted by the New York State Office of Temporary and Disability Assistance (OTDA). It is called a “fair hearing” because both the federal Due Process Clause and New York’s own regulations (Social Services Law § 22 and 18 NYCRR Part 358) require a hearing before government benefits can be cut off. Despite the friendly name, this is a contested legal proceeding, and the agency will be represented. You should be too.

Being polite to the hearing officer (an Administrative Law Judge) will not, by itself, change the outcome. To win, you need to present financial documentation, apply the correct eligibility rules, and cite prior fair hearing decisions that support your position. Equally important, you need to build a clean record. If the hearing decision goes against you, the only way to challenge it in court is through an Article 78 proceeding under CPLR Article 78 — and the Supreme Court can only review evidence that was already placed before the hearing officer.

Which Medicaid Are You Challenging?

The strategy depends on which type of New York Medicaid was denied. Most disputes in NYC involve one of these programs:

• Community (MAGI and non-MAGI) Medicaid for outpatient care, home care, and managed long-term care (MLTC). The 2024 resource limit for the aged, blind, and disabled category is roughly $31,175 for an individual.
• Institutional (chronic-care) Medicaid for nursing home coverage, which carries a 60-month asset look-back and transfer-penalty rules.
• Medicaid for the aged, blind, and disabled (MABD), where spend-down, pooled trusts, and spousal allowances frequently arise.

In New York City, applications are handled by the Human Resources Administration (HRA) Medicaid program rather than a county Department of Social Services. The fair hearing system, however, is the same statewide.

Common Reasons NYC Medicaid Denies an Application

Most denials fall into a handful of categories. Identifying the reason on your Notice of Decision is the starting point for the challenge.

• Excess resources. The agency says your countable assets exceed the limit — the most common reason for an institutional Medicaid denial. The dispute often turns on whether a joint account, an irrevocable trust, or jointly held real property was correctly counted. For example, funds in a properly drafted irrevocable income-only trust outside the look-back are not countable, and contesting an agency’s contrary finding is a frequent winning argument.
• Excess income. The agency says monthly income exceeds the program limit. The challenge usually involves whether certain income should be excluded, whether a pooled income trust can shelter the excess (a recognized spend-down tool under 18 NYCRR § 360-4.5), or whether a spousal income allowance applies.
• Transfer penalty. The agency claims you made uncompensated transfers during the 60-month look-back and imposes a penalty period. Disputes turn on whether transfers were truly uncompensated, whether the penalty was calculated using the correct regional rate, and whether an exemption applies — such as a transfer to a disabled child, the caregiver-child exception, or a transfer to a sibling with an equity interest in the home.
• Failure to provide documentation. The agency says it requested documents you never provided. Often the documents were submitted and lost, or the agency demanded items the regulations do not require.
• Procedural defects. A missing signature, the wrong form, or an incomplete section. These technical denials are frequently the easiest to reverse on a fair hearing.
• Residency or immigration status. The agency contests whether the applicant is a New York resident or holds the immigration status required for full Medicaid coverage.

Deadlines You Cannot Miss

Under 18 NYCRR § 358-3.5, you generally have 60 days from the date of the Notice of Decision to request a fair hearing. If your existing Medicaid is being terminated or reduced (rather than denied for the first time) and you want coverage to continue while the hearing is pending, you must request the hearing within 10 days of the notice and check the “aid continuing” box. This is known as aid continuing, and it keeps your benefits in place until a decision is issued.

Missing the 60-day deadline usually means starting over with a new application. You can request a late hearing and ask for good-cause acceptance, but the standard is strict and rarely granted. Always calculate the deadline from the date printed on the notice, not the date you received it.

How to Request the Fair Hearing

You can request a hearing through OTDA in several ways:

• Online at otda.ny.gov/oah (recommended — you receive a confirmation number).
• By fax to the OTDA fair hearing fax line printed on your notice (keep the transmission confirmation as proof).
• By phone at the statewide fair hearing line, or by mail to the address on your notice.

The request must identify the agency that took the action (HRA Medicaid), the case or client identification number, the date of the notice, and the specific action you are appealing. State that you want aid continuing if it applies. After filing, OTDA schedules the hearing and mails a Notice of Hearing. Most Medicaid hearings in NYC are now held by telephone or video; the notice explains how to participate.

A Sample Fair Hearing Timeline

While every case is different, a typical excess-resources denial often moves like this:

• Day 0: HRA mails the Notice of Decision denying Medicaid.
• Within 10 days: Request the fair hearing with aid continuing (if terminating active coverage).
• Day 0–15: Request the agency’s case file under 18 NYCRR § 358-3.7.
• Day 15–45: Assemble the exhibit binder and submit documents to OTDA in advance.
• Roughly 60–90 days: The fair hearing is held.
• Within 90 days of the request: OTDA issues a written decision (the regulatory standard under 18 NYCRR § 358-6.4).
• Within 4 months of an adverse decision: File an Article 78 petition in Supreme Court if needed.

Preparing for the Hearing

Preparation is the single biggest predictor of success. Start by requesting the agency’s case file. Under 18 NYCRR § 358-3.7, the agency must provide the documents it relied on to make the decision and other relevant material in your file. Review it to understand exactly what the agency considered and what it overlooked.

Then assemble your evidence. The documents that win each category of denial usually include:

• Excess resources: bank and brokerage statements, deeds showing co-ownership, trust instruments, and account ownership records establishing whose money is whose.
• Excess income: the pooled-trust joinder agreement, Social Security and pension award letters, and proof of excluded income.
• Transfer penalty: contracts, appraisals, or caregiver agreements showing fair consideration, plus documentation supporting any exemption (such as a physician’s statement of disability for a disabled-child transfer).
• Failure to document: copies of everything previously submitted, with fax confirmations or certified-mail receipts.
• Residency: lease, utility bills, voter registration, and government correspondence.
• Immigration status: the relevant USCIS documentation.

Organize everything into a tabbed exhibit binder with a cover index, and submit it to the hearing officer in advance. A clean, indexed presentation shows the ALJ you are serious and makes the record easy to review on appeal.

What Happens at the Hearing

The hearing officer is an Administrative Law Judge who hears Medicaid and other public-benefits cases. The agency is represented by a fair-hearing representative — not always an attorney, but someone trained to defend the agency’s position. Each side may introduce documents, call witnesses, and cross-examine the other side’s witnesses. The hearing is recorded, and that record — not the hearing itself — is what a court reviews later.

The ALJ typically reserves decision and issues a written ruling. If you win, the decision directs the agency to take corrective action: approving the application, restoring benefits, or recalculating eligibility. New York fair hearing decisions are publicly searchable in OTDA’s online decision database, and citing on-point prior decisions can be persuasive when the facts mirror yours.

The Article 78 Proceeding

If you lose the fair hearing, the next step is an Article 78 proceeding in New York State Supreme Court. The court does not retry the facts. Its job is to decide whether the agency’s determination was supported by substantial evidence in the record and whether the agency followed the law. That is why building a complete record at the fair hearing is so important — if your evidence is not already in the administrative record, the Supreme Court generally will not consider it.

An Article 78 petition must be filed within four months of the final administrative decision (CPLR 217). Most cases are decided on submitted papers. If you prevail, the court typically remands the matter to the agency for corrective action consistent with its ruling. If you lose, your remaining option is an appeal to the Appellate Division.

Why Representation Matters

Medicaid is a complex, document-intensive program, and the agency’s internal practices are often opaque. Many people who try to handle a denial alone arrive at the hearing without the right documents, without supporting fair hearing decisions, and without a clear legal theory connecting the program rules to their facts. Because the Supreme Court can only review the record built at the hearing, gaps left at that stage are usually permanent.

An attorney can identify the legal theory that best fits your case, request the agency file, gather the supporting evidence, file the proper requests on time, and present the case in a way that creates the record needed for a successful appeal if necessary. The cost of representation is often a small fraction of what is at stake — a denied institutional Medicaid application can mean tens of thousands of dollars per month in private-pay nursing home costs.

Frequently Asked Questions

How long do I have to request a NYC Medicaid fair hearing?

Generally 60 days from the date on the Notice of Decision. If your active Medicaid is being terminated and you want aid continuing, you must request the hearing within 10 days.

Can I keep my Medicaid during the appeal?

Yes, if your existing coverage is being terminated or reduced and you request the hearing within 10 days while electing aid continuing. This is not available for a first-time denial.

What if I miss the 60-day deadline?

You can request a late hearing and argue good cause, but it is rarely granted. In most cases you will need to file a new Medicaid application.

What happens if I lose the fair hearing?

You may challenge the decision through an Article 78 proceeding in New York Supreme Court, filed within four months of the final decision.

Do I need a lawyer for a Medicaid fair hearing?

It is not legally required, but because the hearing record is what controls any later court appeal, experienced representation often makes the difference between approval and a costly denial.

Related Reading

• Benefits of a special needs trust for protecting assets while qualifying for benefits.
• Advanced New York estate planning techniques that affect Medicaid eligibility.
• Asset protection and spousal planning in New York.

Talk to a Medicaid Fair Hearing Attorney

If you have received a notice denying or terminating your Medicaid in New York City, time is short. Contact us promptly so we can review the notice, calendar the deadlines, request the case file, and develop a strategy. We handle fair hearings, Article 78 proceedings, and appellate review of Medicaid decisions throughout New York. You can reach the Law Offices of Albert Goodwin at 212-233-1233 or by email at [email protected].

About the Author

Albert Goodwin, Esq. is the founder of the Law Offices of Albert Goodwin, with offices serving New York City and Long Island. He is admitted to practice law in New York State and concentrates his practice on estate, trust, and elder-law matters, including Medicaid eligibility disputes, fair hearings, and Article 78 proceedings. He has more than a decade of experience representing clients in Surrogate’s Court and administrative proceedings throughout New York. Learn more on our about Albert Goodwin page.

This article is for general informational purposes only and is not legal advice. Medicaid rules and dollar limits change periodically; verify current figures and deadlines with OTDA or an attorney before acting. Reading this page does not create an attorney-client relationship.

Last updated: June 2024.