Thursday, January 28, 2016

Medicaid Appeals FAQ


Q What is an appeal?

A An appeal is asking for a hearing because you do not agree with a decision the Office of Medicaid Policy and Planning (OMPP) has made regarding your eligibility or benefits. The information listed here is for members who are already on Medicaid. If you want to appeal a decision regarding your eligibility for Medicaid, you must follow the process for eligibility appeal that is listed on the notice you received from the Division of Family Resources (DFR). You can learn more about the appeal process here.

Q Is there a charge to file an appeal?

A No. You do not have to pay to file an appeal.

Q How do I appeal?

A If you are enrolled in Hoosier Healthwise or the Healthy Indiana Plan, you must contact your health plan first. You are required to exhaust their grievance and appeals process prior to filing an appeal or grievance with the state.

Your appeal must be in writing. In your letter, tell us why you think the decision is incorrect. Please make sure your name and other important information, such as the date of the decision, are on the letter.

Mail your appeal to:

Family and Social Services Administration
Office of Hearings and Appeals
402 West Washington Street, Room E034
Indianapolis, IN 46204

Eligibility: If you want to appeal a decision made about your eligibility for Medicaid, you must follow the process for eligibility appeal that is listed on the notice you received from the Division of Family Resources. You can learn more about that process here.

Q How long do I have to appeal?

A You must file an appeal:
Within 33 calendar days of the date on the notification; or
Before the date a decision goes into effect, whichever is later.
Can I continue to get benefits when my appeal is pending?

New services cannot be started, but you may keep your current benefits until an appeal is final, if you file an appeal:
within 10 calendar days of the date of the Notice or
before the date a decision goes into effect, whichever is later

Q Am I responsible for payment if my appeal is not overturned?

A Any disputed benefits you receive while your appeal is being decided may have to be paid back if the appeal process determines that the original decision is correct.


Q What is a hearing?

A A hearing is a meeting between you (and any representative) and the State. An Administrative Law Judge (ALJ) will hear both sides and make a decision according to the law. The ALJ is impartial in the appeal. The ALJ will notify both you and the State of their final decision in writing.

Q How will I know if I get a hearing?

A You will be notified in writing of the date, time, and place for the hearing.

Q Can I have someone else help me in the hearing?

A You or someone else, such as a lawyer, friend, or relative, can tell why you disagree with this decision. If you wish to have legal representation and you cannot afford it, you may call Indiana Legal Services.

No comments: