Appealing Medicaid And SSI Decisions: Know Your Rights

By Ann N. Butenhof, CELA & Judith L. Bomster, Esq.

Medicaid and SSI (Supplemental Security Income) are often essential to quality of life for individuals with disabilities. So it can be very stressful if benefits are denied, decreased or terminated. But federal law guarantees the right to appeal if you think a mistake has been made. And while there are strict procedures to follow, appeals are often successful.

Medicaid Appeals

Medicaid is a joint federal/ state initiative, with each state defining and managing its own plan in accordance with national requirements.  Though eligibility requirements vary by state, certain aspects of the appeals process are uniform across the U.S.:

  • Written notice of a decision must be provided and must explain how the state agency reached its determination and how to appeal. If insufficient information is provided for you to determine whether or not the decision was flawed, you should protest not only the decision but the incomplete nature of the notice.
  • The first step in the appeal process is to request a hearing. Although not all states require that this be done in writing, it’s advisable to have proof of your filing date so that your rights are protected if the state claims never to have been notified of the appeal. If you’d like to ask that benefits be continued while the agency’s finding is being appealed, you must file within 10 days of the date cited on the agency’s notice of decision. Be aware that you may be liable for repayment of those temporarily continued payments if your appeal is unsuccessful.
  • Once you have filed your appeal, state Medicaid employees may be willing to discuss your issues, and having a supervisor involved may eliminate the need for a hearing.
  • The hearing, which should be recorded, is conducted by an impartial party who may or may not be an attorney. It’s less formal than a court trial, and you may either represent yourself or choose to use an attorney or other advocate. You can offer evidence, call witnesses and testify yourself. You can also question the Medicaid agency’s witnesses.
  • If the hearing results in another denial, you can appeal through your state’s court system. You should consult an attorney concerning the advisability of proceeding, and whether it would be better to pursue your rights through the state or federal courts.

Supplemental Security Income Appeals

SSI is a federal cash assistance program for individuals meeting the Social Security Administration’s (SSA) definition of disability, as well as income and asset guidelines. In most states, SSI eligibility automatically qualifies an individual for Medicaid, but that is not true in every state.

  • As with Medicaid, an SSI denial or termination of benefits must be in writing and include the basis for the agency’s determination so that you can assess whether or not to appeal.
  • Requests for reconsideration should be made using a form provided by SSA. Requests that terminated benefits be continued pending reconsideration must be filed within 15 days of the date on the notice. Other requests must be filed within 60 days. If there are extenuating circumstances, an additional 60-day extension may be granted for reconsideration requests.
  • There are several types of reconsideration, during each of which you may submit additional evidence:
    • Case review – In some instances, SSA may hear oral evidence, but in most cases, written submissions are required.
    • Informal conference – You may be represented by an attorney and present witnesses, after which SSA summarizes the proceeding and issues a decision. This option isn’t available if the initial denial was based on medical issues or there’s disagreement on a disability’s date of onset.
    • Formal conference – This is available only if existing benefits have been reduced, terminated or suspended. It’s conducted before an impartial party who does not work for SSA, permits cross-examination of SSA witnesses, is recorded and results in a written decision.
    • If the reconsideration process isn’t successful, you can request a hearing using a form provided by SSA. The hearing is conducted before an administrative law judge, and you may introduce witnesses and supplemental medical evidence and may cross-examine SSA witnesses. If possible, you should be represented by legal counsel.
    • The next step, if you receive an unfavorable decision, is to request that the finding be reviewed by the SSA Appeals Council. The Appeals Council does not agree to hear every case and usually reviews only issues of wider significance. A decision not to consider your appeal constitutes SSA’s final decision. If the Appeals Council agrees to review your appeal, it will evaluate the entire written record and any additional documentation that you submit.  No live testimony is involved.
    • The SSA’s final decision may be further appealed in federal district court, and if you continue to be denied benefits, additional appeals may be appropriate.

The appeal process can become very complicated, and in some cases, legal counsel is advisable. Members of the Special Needs Alliance are well versed in the intricacies of both Medicaid and SSI, and can assist you in determining your best course of action.