This document is not legal advice. It only gives general information about Medicaid appeals
Medicaid Appeals
When Medicaid/Family and Social Services Administration (FSSA)/the State decides
something about your Medicaid, you will almost always have a right to appeal that
decision. Medicaid includes all of the following programs: Hoosier Healthwise,
Healthy Indiana Plan (HIP), Children's Health Insurance Program, Hoosier Care
Connect, Medicare Savings Program, and traditional Medicaid.
An appeal means a judge will decide if the State’s decision to change, deny, or
terminate your benefits was right or wrong.
This guide about Medicaid appeals and has three parts:
Facts about Medicaid Appeals
How to start an Appeal and Prepare for a Hearing
What to do at a hearing
Medicaid appeals can be confusing! If you need help understanding your notices or
with the appeals process, there are places you can go. The last page has a list of
places that can help.
Facts about Medicaid appeals
2
Read your Notices
Read your notices carefully and pay attention to dates and reasons for the denial or change.
If you do not understand your notice, ask questions! You ask questions to FSSA about your
Medicaid by calling 1-800-403-0864 or by visiting your local Division of Family Resources
office. More information about finding and contacting your local office is at
https://www.in.gov/fssa/files/DFR_Map_and_County_List.pdf
If you do not understand the answers, seek assistance from an attorney or an Indiana Certified
Navigator. Information about finding assistance from an attorney or a navigator is in the
“Where to find help” section at the end of this document.
You have a right to Appeal
You can appeal most of the State’s decisions about your Medicaid and you should appeal if
you think the State got something wrong.
Common appeal reasons are:
• Your Medicaid application was denied
• The State wants to terminate your Medicaid
• Medicaid category changes (example: Moving from “full” Medicaid to HIP)
• Your required HIP Power Account contribution is wrong
• The effective date of your coverage is wrong
If the incorrect change is the result of a decision by the Managed Care Company, you should
review your member handbook and make a grievance.
Act Quickly
For most Medicaid decisions, you have 33 days from the date on your notice to file an appeal.
This is a strict deadline. Appeal quickly. In some cases, if you appeal within 10 days of the
notice or before the effective date, you may be able to continue your benefit without changes
until your hearing.
If you are not sure whether you should appeal, you should appeal. You can withdraw your
appeal later if you are certain your issue is resolved.
Re-apply
If your Medicaid coverage is stopped or your application is denied, you can re-apply and
appeal. Re-applying may get your coverage re-started sooner. If you win your appeal, you
may be able to recover out-of-pocket medical expenses you paid while you waited for your
hearing.
How to start an Appeal and Prepare for a Hearing
3
The notice you are trying to appeal should have appeal information. Detailed information
about appeals is at https://www.in.gov/oalp/resources-for-fssa-appeals/
Ask for a hearing in writing
The State has a form you can use, but you can also write a letter. It is a good idea to attach a
copy of the notice you are appealing. The state form is at
https://www.in.gov/fssa/dfr/files/Administrative_Appeal_And_Hearing_Request_SF53932.pdf
After you fill out the form, Mail/Fax/deliver your request for a hearing within 33 days of the
date of the notice you are appealing.
Mail: FSSA Document Center PO Box 1810 Marion, Indiana 46952
Fax: 1-800-403-0864
Visit your local DFR/Medicaid Office.
Attend a Pre-hearing conference
The State should contact you for a Pre-Hearing Conference. This is an opportunity to ask
questions about your case. This is done over the phone, so it is important that Medicaid has
your correct phone number.
During the conference the State may ask you to withdraw your appeal. You are not required
to withdraw your appeal! If you are not satisfied that the problem has been resolved, you
should not agree to withdraw your appeal.
Request the State’s Exhibits/Evidence
You have a right to view the State’s evidence before the hearing. You must ask for the state’s
exhibits in writing. It is a good idea to ask for this when you make your hearing request.
Give the State your Exhibits/Evidence
You should give your exhibits and evidence to the State before the hearing. You can mail, fax
or email it.
Mail: Office of Administrative Law Proceedings – FSSA Hearings
402 W. Washington St., Rm E034
Indianapolis, IN 46204
Fax: 317-232-4412
Email: fssa.appeals@oalp.in.gov
Rescheduling your hearing
If you need to reschedule your hearing, you can contact the hearing office by calling 317-
234-3488 or 1-866-259-3573
What to do at a Hearing
4
Where your hearing will be
Hearings are conducted by phone or in person. You may have to specifically request an in-
person hearing. You will be mailed instructions about how to attend your hearing, including
how to call in if your hearing is by phone.
Who will be at the hearing
There will be at least three people at your hearing: you, the State and the Administrative Law
Judge.
The State will be represented by a worker (usually not an attorney) and may also bring
witnesses.
You can bring witnesses and present evidence- even if you did not submit evidence ahead of
time.
During the hearing
The hearing is informal, but you will swear to tell the truth. Each side will get a turn to talk.
The State will explain why it took the action it did. You can ask the State questions.
When it is your turn, you should explain to the judge why the State’s action was wrong. You
should give the judge all the evidence that shows why the State’s decision is wrong.
The hearings are recorded so you should speak slowly and clearly.
After the hearing
After the hearing the judge will mail you a decision. The decision will tell you if you won and
will explain the reasons for the judge’s decision.
If you disagree with the judge’s decision, you can appeal it. The decision will have
information about how to appeal. Like with asking for an appeal, you will need to act quickly.
Where to find help
5
Right to Language Services
If English is not your first language, you may need assistance with translation throughout this
process. You have a right to request this assistance from FSSA. Seek legal assistance (see
below) if any State agency refuses translation assistance.
Indiana Legal Services, Inc.
Indiana Legal Services (ILS) provides free legal advice and representation to low-income
Hoosiers on a variety of legal issues, including Medicaid.
To get help from ILS, you need to do an intake. You can do an intake by phone at 844-243-
8570 Monday-Friday 8-12 Eastern /9-1 Central or online at
https://www.indianalegalservices.org/applyonline
Authorized Representative
An authorized representative can help communicate with Medicaid on your behalf.
Any trusted person can be your authorized representative and can help you with your
application. More information about Authorized Representatives is at
https://www.in.gov/fssa/dfr/becoming-an-authorized-representative/
Managed Care Organization (MCO)
The MCOs that contract with the State to administer Indiana’s Medicaid are Anthem,
CareSource, MDwise, Managed Health Services (MHS), and United Healthcare. MCOs can
help resolve some types of issues on behalf of their clients, especially if it is related to
coverage or a category change. Your Medicaid card will have contact information for your
MCO.
Certified Navigators
An Indiana Certified Navigator may be able to help you apply for coverage, update your
contact information, advocate for you with the State, understand your notice, or start an
appeal.
Many hospitals, non-profits and federally qualified healthcare centers have navigators on
staff. You can find Indiana Certified Navigators by visiting https://in-fssa.force.com/HCNav/.
American Bar Association (ABA)
You can ask a lawyer legal questions at https://indiana.freelegalanswers.org/.
