Medicaid Fair Hearing Montana: How to Appeal a Denial
The 90-Day Deadline
When DPHHS denies a Medicaid long-term care application or reduces existing benefits, the applicant has exactly 90 days from the date on the written denial notice to request a fair hearing. Miss this window and the right to appeal that specific decision expires.
The denial notice itself contains critical information: the specific reason for denial, the regulations cited, and instructions for requesting a hearing. Read it carefully — the stated reason determines how you prepare your case.
Common denial reasons include countable assets exceeding $2,000, failure to provide requested documentation within the deadline, clinical screening results that do not meet nursing facility level of care, or transfer penalties from the 60-month lookback period.
How to Request a Fair Hearing
File a written request with the DPHHS Quality Assurance Division. The request does not need to be a formal legal document — a clear letter stating that you are appealing the denial, identifying the applicant, referencing the denial notice date, and explaining why you believe the decision is wrong is sufficient.
Send the request by certified mail so you have proof of the filing date. The mailing address is on the denial notice. Keep a copy of everything you send.
If the denial involves a reduction or termination of benefits the applicant is currently receiving, requesting the hearing before the effective date of the change triggers aid-paid-pending. This means benefits continue at the current level until the hearing is resolved. If you wait until after benefits have already been cut, you lose this protection.
What Happens at the Hearing
A fair hearing is an administrative proceeding, not a court trial. An administrative law judge from the Office of Administrative Hearings presides. The process is less formal than a courtroom but follows structured rules:
The applicant (or their representative) presents their case first. This means explaining why the denial was wrong, presenting evidence, and answering the judge's questions.
DPHHS then presents its position — typically the caseworker or eligibility specialist who made the original decision explains their reasoning and the documentation they reviewed.
Both sides can present witnesses, submit documents, and respond to the other side's arguments.
Hearings can be conducted in person, by phone, or by video. Ask the Office of Administrative Hearings which format applies to your case.
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Building Your Case
The strongest appeals focus on one of three angles:
Documentation errors. DPHHS miscounted an asset, misclassified an exempt resource as countable, or failed to account for excluded income. If the agency counted a prepaid irrevocable burial plan as a countable asset, for example, that is a factual error you can correct with the plan documentation.
Calculation mistakes. The transfer penalty was computed incorrectly, the community spouse resource allowance was not properly applied, or the medically needy spend-down was calculated using wrong figures. Bring your own calculations with supporting documentation.
Missing context. Documents were submitted but not received or processed, medical records were incomplete at the time of the clinical assessment, or circumstances changed between application and denial (a transfer was cured by returning gifted assets, for instance).
Gather every piece of supporting evidence before the hearing date. Bank statements, medical records, property appraisals, transfer receipts, correspondence with OPA — anything that contradicts the stated reason for denial.
Free Legal Help
The Montana Legal Services Association (MLSA) provides free legal representation in Medicaid appeal matters for qualifying applicants. Their HelpLine number is 1-800-666-6899. MLSA attorneys handle fair hearings regularly and understand the specific procedural requirements.
If you do not qualify for MLSA services, the State Bar of Montana's Lawyer Referral Service can connect you with an elder law attorney. Legal representation is not required for a fair hearing, but having someone who knows how DPHHS calculates eligibility significantly improves outcomes.
After the Hearing
The administrative law judge issues a written decision. If the decision reverses the denial, DPHHS must implement the ruling; ask DPHHS or MLSA how any retroactive coverage should be handled.
If the decision upholds the denial, ask the Office of Administrative Hearings, MLSA, or an attorney about any further review and the deadline that applies to your case.
For a structured walkthrough of the eligibility criteria, documentation requirements, and appeal strategies, the Montana Medicaid Long-Term Care & Asset Protection Guide covers the entire process from initial application through denial resolution.
Get Your Free Montana — Medicaid Long-Term Care Eligibility Checklist
Download the Montana — Medicaid Long-Term Care Eligibility Checklist — a printable guide with checklists, scripts, and action plans you can start using today.