How to Appeal a Medicaid Denial in Delaware

Getting a Medicaid denial letter while your parent is already in a nursing home at $14,494 a month is a gut punch. But a denial isn't the end — it's a decision that can be reversed. Delaware provides a formal appeals process, and a significant number of denials result from fixable issues rather than genuine ineligibility.

The 60-Day Deadline

Delaware gives you 60 days from the date on the denial notice to request a State Fair Hearing. This deadline is strict. If you miss it, you lose the right to appeal that specific denial and would need to file a new application from scratch.

Don't wait until day 59. Request the hearing as soon as you understand the reason for the denial and have a plan to address it.

How to Request a Hearing

Submit a written request to the Division of Social Services. The denial notice itself typically includes instructions and a form for requesting a Fair Hearing. Delaware's DHSS also accepts written requests by email at [email protected].

In your request, briefly state why you believe the denial was wrong. You don't need a detailed legal brief at this stage — just enough to identify the disputed issue.

Preserving Benefits During the Appeal

If your parent was already receiving Medicaid benefits and the denial is a termination (rather than an initial application denial), request continuation of benefits by the deadline in the notice. A timely request can keep Medicaid-covered care in place throughout the appeal process — this is called "aid paid pending."

For initial application denials, there's no continuation of benefits to preserve — your parent wasn't receiving them yet. In that case, the appeal is about getting approved, and the family covers care costs in the interim.

Common Reasons for Denial (and How to Fix Them)

Most long-term care Medicaid denials in Delaware fall into a few categories:

Excess assets. DMMA determined that countable resources exceed the $2,000 individual limit. The fix is often documentation — proving that certain assets are actually exempt (the vehicle, the home, a funeral trust), or completing additional spend-down and submitting updated bank statements.

Missing or improperly funded Miller Trust. If your parent's income exceeds $2,485 and the Qualified Income Trust wasn't established and funded in the application month, the application fails. The fix is setting up the trust, funding it for the correct month, and reapplying or presenting the corrected documentation at the hearing.

Incomplete documentation. DMMA requested bank statements, income verification, or asset documentation that was never submitted or arrived after the processing deadline. At the hearing, provide the missing documents.

Level-of-care determination. The clinical review concluded your parent doesn't meet the nursing home level of care. This requires medical evidence — updated physician statements, detailed documentation of ADL limitations, cognitive evaluations for dementia patients. The PAE Tool-001 may need to be resubmitted with more thorough clinical documentation.

Transfer penalty. DMMA identified uncompensated transfers during the lookback period. If the transfer was legitimate (to a spouse, disabled child, or caretaker child meeting the exemption criteria), provide evidence of the exemption. If it was an actual gift, the "cure" option — returning the assets — can eliminate the penalty.

What Happens at the Hearing

A Fair Hearing is conducted by an impartial hearing officer from the Division of Social Services. It's less formal than a courtroom proceeding but follows a structured process. You present evidence, explain your position, and can bring witnesses. DMMA presents its rationale for the denial.

You have the right to:

• Review your parent's complete Medicaid case file before the hearing
• Bring an attorney or authorized representative
• Present documents, medical records, and witness testimony
• Cross-examine state witnesses

The hearing officer issues a written decision within 30 days of the hearing.

When to Get an Attorney Involved

Simple documentation fixes — submitting missing bank statements, providing proof of an exempt asset — usually don't require legal representation. But if the denial involves a transfer penalty dispute, a level-of-care disagreement, or a complex financial situation, an elder law attorney can significantly improve the outcome. The cost of a few hours of legal representation is minor compared to months of private-pay nursing home costs.

For families preparing to navigate the appeal process themselves, the Delaware Medicaid Long-Term Care & Asset Protection Guide includes pre-written appeal letter templates and a document checklist organized by denial type.

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