How to Appeal a Medicaid Denial in New York (Fair Hearing)

Your parent's Medicaid application was denied, or their home care hours were slashed without warning. Before you panic, know this: New York gives you the right to challenge virtually any Medicaid decision through a Fair Hearing — and if you act fast enough, you can keep existing services running while the appeal is decided.

What You Can Appeal

Fair Hearings cover almost any adverse action by the local Department of Social Services (DSS), HRA, or an MLTC plan:

• Application denial — Medicaid determined your parent doesn't qualify financially or clinically
• Reduction in services — approved home care hours were decreased
• Termination of services — Medicaid coverage or home care is being cut off entirely
• Failure to act — the agency hasn't processed the application within required timeframes
• Nursing home discharge — the facility is trying to discharge your parent involuntarily

Each of these triggers a written notice from the agency explaining the action and your parent's right to appeal. The appeal clock starts when the notice is received.

How to Request a Fair Hearing

You can request a Fair Hearing through multiple channels:

• Online: Through the New York Office of Temporary and Disability Assistance (OTDA) website
• Phone: Call the OTDA Fair Hearing hotline
• Fax or mail: Submit a written request to the OTDA Fair Hearing Section in Albany

The request doesn't need to be formal or elaborate. A simple written statement identifying your parent, the agency that took the action, and a brief description of what you're contesting is sufficient to start the process.

Deadline: You generally have 60 days from the date of the adverse notice to request a hearing. But the real deadline that matters is much shorter — read the next section.

Aid Continuing: The 10-Day Window

If your parent is already receiving Medicaid services and those services are being reduced or terminated, you have 10 days from the date of the adverse action notice to request a Fair Hearing with Aid Continuing.

Aid Continuing means the agency must keep providing the current level of services — the same home care hours, the same coverage — while the appeal is pending. Without it, your parent loses services immediately and may not get them back for months.

The 10-day window is absolute. Miss it by a day, and your parent's services stop while you wait for the hearing. This is the single most important deadline in the entire Medicaid system.

One caution: if you lose the Fair Hearing after receiving Aid Continuing, your parent may be required to repay the cost of services provided during the appeal period. In practice, this rarely happens for low-income applicants, but it's a risk worth understanding.

Preparing for the Hearing

Fair Hearings are conducted by an Administrative Law Judge (ALJ) from the OTDA. They can be held in person, by telephone, or by video. The hearing is less formal than a courtroom proceeding but follows similar principles — both sides present evidence and the ALJ makes a determination.

What strengthens your case:

• Your parent's physician's letter documenting functional limitations and care needs
• ADL documentation — a daily log showing what tasks your parent needs help with
• The original NYIAP assessment (request a copy if you don't have it)
• Documentation that the agency made procedural errors (missed deadlines, failed to consider evidence)
• Evidence that your parent's condition has worsened since the original assessment

What to expect: The agency presents its case for the denial or reduction, typically citing the NYIAP assessment findings or financial eligibility calculations. You present evidence showing why the decision was wrong. The ALJ issues a written decision, usually within 60-90 days.

Representation: You don't need a lawyer, but legal representation significantly improves outcomes. The Legal Aid Society, New York Legal Assistance Group (NYLAG), and local legal services organizations provide free representation for Medicaid Fair Hearings.

When the Denial Is About Clinical Eligibility

Many denials stem from the September 2025 minimum needs requirements — the NYIAP assessment found your parent needs help with only 2 ADLs instead of the required 3 (or 1 ADL instead of 2 for dementia patients).

Challenge strategies:

• Get a detailed physician letter that contradicts the NYIAP findings. Your parent's doctor knows their functional limitations better than an assessor who spent two hours observing.
• Document bad assessment days. If the assessment happened on an unusually good day, gather evidence of what your parent's typical day actually looks like.
• Request a new assessment. If your parent's condition has deteriorated since the original evaluation, you can request a reassessment and file the Fair Hearing simultaneously.

The New York Medicaid Long-Term Care Guide includes a Fair Hearing preparation checklist covering documentation, common agency arguments, and response strategies for each type of denial.

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