How To Challenge a Denial of NYC Medicaid

What do you do when Medicaid has been denied? The first thing to do is file a request for a fair hearing. “Fair hearing” means Medicaid court. It’s called “fair hearing” because the Constitution requires a fair hearing before government benefits can be terminated. Do not be mislead by this term – this is an administrative proceeding for which it is essential to be represented by an attorney.

Just being nice to the hearing officer (essentially, a judge) will not help. Quite the opposite – you need an attorney to aggressively argue your case and to present points of law and prior decisions to prove that you qualify for Medicaid.

When arguing before the fair hearing officer, it is essential to establish a record so that if the decision is not in your favor, it can be challenged in an Article 78 proceeding in New York Supreme Court. The Department of Social Services is a New York State entity and follows the law, so winning the fair hearing or the Supreme Court Article 78 procedure will mean qualifying for New York Medicaid.

Common Reasons NYC Medicaid Denies an Application

Most Medicaid denials in New York City fall into a handful of categories. Understanding why your application was denied is the starting point for figuring out how to challenge it.

• Excess resources. The agency says your countable assets are above the limit. This is the most common reason for an institutional Medicaid denial. The dispute often turns on whether a particular asset (a joint account, a trust, a property held with a relative) was correctly counted.
• Excess income. The agency says your monthly income exceeds the program limit. The challenge usually involves whether certain income should be excluded, whether a pooled trust can be used to shelter the excess, or whether a spousal allowance applies.
• Transfer penalty. The agency claims you made uncompensated transfers during the look-back period and is imposing a penalty period during which Medicaid will not pay. Disputes here turn on whether transfers were actually uncompensated, whether the look-back period was correctly applied, and whether any exceptions (transfers to a disabled child, certain caregiver child transfers of the home) apply.
• Failure to provide documentation. The agency says it requested documents and you did not provide them. Often the documents were sent and lost, or the agency demanded items that the law does not require.
• Procedural defects in the application. Sometimes the agency denies for technical reasons – the wrong form, a missing signature, an incomplete section. These are often the easiest denials to reverse on a fair hearing.
• Residency or immigration status. The agency contests whether the applicant is a New York resident or has the immigration status required for full Medicaid coverage.

Deadlines You Cannot Miss

The deadline to request a fair hearing is generally 60 days from the date of the notice of action. The deadline is shorter – just 10 days from the notice – if you want to keep your benefits in place while the hearing is pending in a case where your existing Medicaid is being terminated rather than denied for the first time. This is called "aid continuing." If you file within the 10-day window and check the aid-continuing box on the request form, your Medicaid coverage continues until a decision is issued.

Missing the 60-day deadline almost always means you have to start over with a new application. You can request a hearing late and ask for good-cause acceptance, but the standard is strict and granting is not common. Calendar these deadlines from the date on the notice, not the date you received it.

How to Request the Fair Hearing

You can request a hearing online through the New York State Office of Temporary and Disability Assistance website, by phone, by fax, or by mail. We generally recommend using the online system or fax so that you have proof of submission. The request needs to identify the agency that took the action, the case number, the date of the notice, and the action you are appealing. You should also state that you want aid continuing if applicable.

Once the request is filed, the state schedules a hearing. The hearing is held telephonically or remotely in most cases. The notice of hearing tells you the date, time, and how to participate.

Preparing for the Hearing

Preparation is the single biggest predictor of success. Start by getting the case file. Under the Medicaid regulations, the agency must provide you with the documents it used to make the decision and any other relevant material in your file. Review the file carefully to understand exactly what the agency relied on and what it might have missed.

Then assemble your evidence. This typically includes:

• Bank statements, brokerage statements, and other financial records that support your position on resources and income.
• Documentation of any transfers, including the reason for the transfer and the consideration received.
• Medical records and diagnostic documentation if level-of-care is at issue.
• Powers of attorney, trust documents, and any caregiver contracts.
• Proof of residency – lease, utility bills, voter registration.
• Proof of immigration status if applicable.

Organize the documents into an exhibit binder with a cover index. Submit them to the hearing officer in advance whenever possible. A well-organized presentation makes the hearing go more smoothly and shows the hearing officer that you are serious.

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 a lawyer, but someone trained to defend the agency's position. You or your attorney presents your case first or second depending on what is being challenged. Each side can introduce documents, call witnesses, and cross-examine the other side's witnesses.

The hearing is recorded. The hearing officer typically reserves decision and issues a written decision within 90 days of the hearing date. If you win, the agency is directed to take corrective action – usually approving the application, restoring benefits, or recalculating eligibility. If you lose, the next step is an Article 78 proceeding.

The Article 78 Proceeding

An Article 78 proceeding is a special form of court action in New York Supreme Court used to review administrative decisions. The court will not reweigh the evidence – its job is to determine whether the agency's decision was supported by substantial evidence in the record and whether the agency followed the law. That is why building a clean record at the fair hearing matters so much. If you do not put your evidence in front of the hearing officer, the Supreme Court generally will not consider it.

Article 78 petitions must be filed within four months of the final administrative decision. The case is decided on submitted papers in most situations. If you win at Article 78, the case is typically remanded back to the agency for corrective action consistent with the court's decision. If you lose, your remaining option is an appeal to the Appellate Division.

Why Representation Matters

Medicaid is a complex program. The regulations are detailed, the agency's practices are often opaque, and the documentation required can be extensive. Many people who try to handle a denial themselves do not realize what evidence they need to put on the record. They get to the hearing without documents, without prior fair hearing decisions supporting their position, and without an understanding of how the program rules apply to their facts.

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

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. Call us promptly so we can review the notice, identify the deadlines, and develop a strategy. We have handled 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].