How to Appeal a Medicaid Denial in West Virginia for Long-Term Care

A Medicaid denial letter doesn't mean your parent can't get coverage. In West Virginia, families have a clear right to challenge the decision through an administrative fair hearing — and denials based on miscounted assets, missed documentation, or borderline clinical scores get reversed more often than most people realize.

The 90-Day Window

When the county Department of Human Services (DoHS) denies a long-term care Medicaid application, they issue a Notice of Decision (NOD). You have 90 days from the date on that notice to file a Request for Fair Hearing using Form DFA-FH-1. Miss that deadline and the denial stands — you'd need to file an entirely new application.

File the request at your local county DoHS office or mail it directly to the Board of Review. Keep a copy with a timestamp.

Common Grounds for Reversal

Most long-term care Medicaid denials fall into one of three categories, each with a different appeal strategy:

Financial denial — assets over $2,000. The caseworker may have incorrectly counted an exempt asset. In West Virginia, the community spouse's retirement accounts (IRAs, 401(k)s) are explicitly exempt. So is the primary home when a spouse or dependent child lives there, one vehicle, household goods, and irrevocable prepaid burial funds up to $1,500. If the denial counted any of these, you have strong grounds.

Financial denial — transfer penalty. If the caseworker flagged an asset transfer within the 60-month lookback window, verify whether the transfer qualifies for an exception. Federal law exempts transfers to a spouse, to a blind or disabled child, to a trust for a disabled individual, or transfers where the applicant can demonstrate the transfer was exclusively for a purpose other than qualifying for Medicaid. If the gifted asset was returned before the application was processed, the penalty should be recalculated or eliminated.

Clinical denial — insufficient PAS score. The Pre-Admission Screening (PAS-2000) requires five functional deficits to qualify. If your parent scored four, the appeal should include additional medical documentation from their physician — particularly for cognitive deficits that may not present clearly during a single in-home assessment. Ask the doctor to submit a detailed letter describing daily functional limitations that the screening nurse may not have observed.

The Fair Hearing Process

The hearing is conducted by a Board of Review Commissioner at the DoHS. You can represent your parent yourself — no attorney is required. Bring:

• The Notice of Decision (the specific denial reason)
• All financial documents the caseworker reviewed
• Any additional records that weren't included in the original application
• A physician's letter if the denial was clinical
• Written statements from family members who can describe the applicant's daily care needs

The Commissioner reviews the evidence and issues a written decision. If the appeal succeeds, Medicaid coverage is typically backdated to the original application date — which means the nursing home or home care agency gets paid retroactively for services already provided.

While the Appeal Is Pending

If your parent was already receiving Medicaid benefits and the state is reducing or terminating coverage, you can request that benefits continue unchanged during the appeal period — but only if you file the hearing request within 10 days of the adverse notice. This "aid-paid-pending" protection doesn't apply to initial application denials, only to changes in existing coverage.

For initial denials, the practical question is how to cover care costs during the appeal. If your parent is in a nursing home, most facilities will continue providing care and bill retroactively once Medicaid is approved. Get this in writing from the facility's billing department.

Don't Reapply Without Appealing First

Filing a new application instead of appealing wastes time — the new application starts the clock over on processing, and any transfer penalty identified in the first application will be flagged again. If the denial was based on a factual error, an appeal corrects it faster than a reapplication.

The West Virginia Medicaid Long-Term Care & Asset Protection Guide covers each denial category in detail, including the specific documentation needed to challenge transfer penalties and the exact process for requesting a fair hearing before the Board of Review.

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