Appeals — State / Medicaid Decisions

If you get a decision from Medicaid or another state health care program and you don’t agree with it, you can appeal the decision. Medicaid and state health care program appeals fall into two major categories:

covered services appeals
eligibility appeals.

A covered services appeal is when you are already on Medicaid—and Medicaid says it won’t cover a procedure or medication.

An eligibility appeal is when Medicaid says that you are not eligible for a program such as Medicaid or Dr. Dynasaur.

There are different rules and timelines for eligibility and covered services appeals, so it is important to understand what you are appealing.

Covered services appeals

If Medicaid denied a covered service, you can appeal their decision. Covered services include:

medical procedures
appointments
prescriptions
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 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.

More information

Visit our page on Fair Hearings to find out more.

Eligibility appeals

If you applied for a state health care program such as Medicaid, Dr. Dynasaur or VPharm, and the State of Vermont says that you are not eligible, you can appeal this decision. You can also appeal if the state tells you are no longer eligible for a program. You have 90 days from the date of the decision to ask for a fair hearing.

Read the information above about requesting a fair hearing and see our page on Fair Hearings to find out how to prepare.

If you have a medical emergency, file your notice to request an appeal immediately, and ask for an “expedited appeal.”

Medicaid denied a non-covered service

If you get a denial, and Medicaid says it is because Medicaid does not cover the service, you can request what is called a 7104 Review or “exception request.” This is basically a request that Medicaid make an exception and cover the service for you because of your special circumstances.

For example, there are some services and medications that Medicaid does not cover for anyone on the program. If you request Medicaid pay for one of these benefits, you will get a denial explaining that the requested benefit is not a covered service.

7104 is a Medicaid rule that may let Medicaid cover services that are not included on the list of covered services and items. This means Medicaid could pay for a benefit that is not normally covered. To get Medicaid to cover the service, you need to show that the service is medically necessary and specifically meets 10 Medicaid standards.

You can download and print our flyer about the 10 standards.

Follow this link to a web page with the text of the 10 standards flyer.
Our PDF file does not fully comply with all applicable guidelines for accessible digital documents. For the most accessible experience, use the link above.
Download a PDF of the 10 standards flyer.

How do I show Medicaid I meet the 10 standards?

To show Medicaid that you meet the 10 standards, you can print the forms listed below for you and your doctor to fill out. You can also call Green Mountain Care Member Services at 1-800-250-8427 and ask that they send the forms to you.

These two forms are found in this one document:

Patient Request for Medicaid Coverage Exception form
Provider Request for Coverage Medical Need form

You need to fill out the Patient Request for Medicaid Coverage Exception form. Your health care provider needs to fill out the Provider Request for Coverage Medical Need form. Ask your provider to write a detailed letter that explains why the service is medically necessary for you. The letter needs to show specifically how the service meets all 10 of the “medically necessary” standards.

Make a copy of the forms and the letter from your health care provider. Send the original letter and forms to the address on the bottom of the form. Keep a copy of the letter and forms for your records. You may need them later.

This can be a difficult process. If you need help, please call us at the Office of the Health Care Advocate at 1-800-917-7787 or fill out our form to ask for help.