If Medicaid denied a covered service, you can appeal their decision. Covered services include:
- medical procedures
- medical equipment
If Medicaid won’t pay for a medical service you need, they will send you a letter explaining why they will not pay. The denial letter may say what you are requesting is being denied for one of the following reasons:
- It is not medically necessary.
- It is not a service Medicaid covers.
- It requires a Prior Authorization (prior approval) from Medicaid.
- Medicaid does not have enough information to make a decision.
The Office of the Health Care Advocate can talk with you about the denial and discuss your options. Contact us at the Office of the Health Care Advocate (HCA) by filling out this form or calling 1-800-917-7787. Our help is free. If you have a time-sensitive, urgent need, please call us instead of using our form.
If Medicaid says they will not pay for a covered service and you want to appeal, you first need to ask for an internal appeal.
Covered services appeals: How to ask for an internal appeal
You have 60 days from the date of the notice to ask for the internal appeal. Ask for the appeal by calling Green Mountain Care (1-800-250-8427) or Vermont Health Connect (1-855-899-9600). You must ask for an internal appeal before you can have a fair hearing.
If you have a medical emergency, file your notice to request an appeal immediately, and ask for an “expedited appeal.”
After you request the appeal, you will get a notice with an appeal date. You can participate by phone or go in person. At the internal appeal someone from Medicaid (who did not make the first decision) will review your case.
During the appeal, you can say why you need this service. You can also share information and evidence showing why you need this service. For example, you may want to have your doctor write a letter of support. Medicaid will consider your evidence and make a decision within 30 days of your appeal.
If you qualify for an expedited appeal, you will get a decision within 72 hours.
After the internal appeal, if Medicaid still says it won’t pay for a covered service, you can request a fair hearing. You have 120 days after the resolution of the internal appeal to request a fair hearing.
Covered services appeals: Requesting a fair hearing
A fair hearing is a legal proceeding used to appeal any decision the state makes. The hearing is informal and is like a meeting.
The fair hearing process is completely confidential. It usually takes a few weeks to get a decision, but it can take a few months or longer.
In coverage appeals, you have 120 days after the resolution of the internal appeal to ask for a fair hearing. If you request a fair hearing by mail, you should mail it at least two weeks before the deadline.
If you are appealing because you are losing benefits, you may be able to get “continuing benefits.” Continuing benefits means that you can keep your current coverage until your appeal is over.
To have a fair hearing with continuing benefits, you must:
- appeal before your benefits change, and
- keep paying your premiums!
Call Green Mountain Care Member Services at 1-800-250-8427 to ask for a fair hearing. Write down who you spoke to and what day and time you called. If you want continuing benefits, tell them that. You can also write to Member Services to request a fair hearing:
Green Mountain Care Member Services
Department of Vermont Health Access
101 Cherry Street, Suite 320
Burlington, VT 05401
You probably will not find out on the day of your hearing if you won. The hearing officer will write a recommended decision and will mail copies to you, the Assistant Attorney General (AAG) and the Human Services Board (HSB). A few weeks later, the HSB will have a meeting in Montpelier to discuss your appeal and the hearing officer’s recommended decision. The HSB meets about every five weeks. It will mail its decision to you.
Visit our page on Fair Hearings to find out more.