This flyer explains your right to appeal decisions the State of Vermont makes about your health care. It tells you how to ask for a fair hearing. It tells you what you need to do to prepare and what to expect. Learn more on our fair hearings page.

Find the PDF file below this text. 
 

No, I Disagree. I Want a Fair Hearing!

I just got a letter from the State of Vermont about my health care and I don’t agree with the decision. What can I do?

You can appeal. You have the right to appeal any decision the state makes. This includes decisions about whether or not you can get insurance, or decisions about what your insurance will pay.

A state appeal is called a fair hearing. The appeal process is completely confidential. It usually takes a few weeks to get a decision, but it can take a few months or longer.

If Medicaid Denied a Service: If Medicaid denied a covered service, you can appeal their decision. Covered services include medical procedures, appointments, prescriptions and medical equipment. You must start by asking for an internal appeal within 60 days of the date of the decision. (An internal appeal can also be called an “MCO appeal.” See our vtlawhelp.org/health website for details.) If you are not satisfied with the result after the internal appeal, you can then ask for a fair hearing within 120 days of the internal appeal decision.

If You Applied for a State Health Care Program: If you applied and you were found ineligible, you can ask for a fair hearing right away. You have 90 days from the date on your denial letter to ask for a fair hearing.

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!

How do I ask for a fair hearing?

Call Green Mountain Care (1-800-250-8427) or Vermont Health Connect (1-855-899-9600) 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 want continuing benefits and the fair hearing.

After you appeal…

You can’t talk to the state about your fair hearing after you appeal. If you need to get copies of letters or any other information from the state, contact the Assistant Attorney General (AAG) at 802-769-2160. The AAG is the state’s lawyer. The AAG should be able to provide you with any information you need for your case.

HSB = Human Services Board

AAG = Assistant Attorney General, the state’s lawyer

What if I have documents or other proof that I’m right?

Make copies and send your proof to the state before the hearing. Send one copy to the Human Services Board (HSB) at:

Human Services Board
14-16 Baldwin Street, 2nd Floor
Montpelier, VT 05633

and one copy to the AAG at:

Office of the Assistant Attorney General
HC 2 North, 280 State Drive
Waterbury, VT 05671

When and where will my fair hearing be?

You will get a letter from the Human Services Board a few days after your fair hearing request. The HSB sets up the fair hearing, usually as a phone conference.

The letter from the HSB will tell you when the hearing will be and what phone number to call to participate in the hearing. The date of the fair hearing will likely be two to three weeks after you get the letter. Call the HSB (802-828-2536) if you do not receive a letter or if you cannot call into the hearing on that date. If you would like a witness to be able to call into the hearing, ask the HSB (802-828-2536) how to set this up.

What will the hearing be like?

You will be on a conference call with the hearing officer and the AAG. The call will be recorded. You can ask the HSB ahead of time to add a person that you want to be on the call with you. The hearing officer will put you and all witnesses under oath to tell the truth.

Focus on convincing the hearing officer that you are right. The hearing officer will tell the HSB if it should change the original decision made by the state.

The AAG will tell the hearing officer that you are wrong and the state is right. Don’t let this worry you! You can still win.

The AAG and the hearing officer will ask you and your witnesses questions. If you don’t understand something, tell them. You can also ask questions.

If you don’t understand what is happening, ask the hearing officer. Ask what information or proof you could get that would make the hearing officer agree with you.

Do I need a lawyer?

Most people don’t have lawyers for fair hearings. But you don’t have to be on the call alone – friends and witnesses can be on the call too. Sometimes, the Office of Health Care Advocate can get someone to help you on the call.

What do I need to do at the fair hearing?

Plan ahead. Write down an outline or checklist so you won’t forget anything.

a) Introduce yourself. Explain what you want to happen and why.

b) Tell the hearing officer what happened and why you are appealing. Be prepared to give a summary of what has happened, and what you think should have happened. Start with what happened first.

c) Bring evidence to support your side. Give them your proof (sections of your handbook, regulations, laws, notices, letters from doctors, medical records, pay stubs, etc.).

If you have a witness, tell the hearing officer. The state will disagree with you. Be prepared to explain why they are wrong.

d) The hearing officer and AAG will ask you and your witnesses questions.

The AAG may also bring witnesses to explain why the state is right. You can ask the AAG’s witnesses questions.

e) Make sure to say again what you want the state to do and why.

How do I convince the state to pay for medical care? 

Letters of support from doctors are very important if you were denied medical care. The letters should say why the service you want is medically necessary and give details. Call the Office of the Health Care Advocate (1-800-917-7787) for specific advice.

Will I find out on the day of my hearing if I won?

Probably not. The hearing officer will write a recommended decision and will mail copies to you, the AAG and the HSB. A few weeks later, the Human Services Board will have a meeting in Montpelier to discuss your appeal and the hearing officer’s recommended decision. The whole process can take up to a few months.

Have more questions? Contact the Office of the Health Care Advocate if you want specific advice for your situation.

1-800-917-7787

vtlawhelp.org/health

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