Montana Medicare Savings Program Denial: How to Appeal Through DPHHS

Understanding the Denial Notice

When DPHHS denies your Medicare Savings Program application — or terminates existing coverage — you'll receive a formal Notice of Decision. This notice contains the determination code, the income and resource figures the agency used, the effective date, and instructions for requesting a fair hearing.

Read the income calculation section carefully. The most common denial reasons are countable income above the program threshold or countable resources above the limit. But DPHHS sometimes makes errors: counting an asset that should be exempt (like the primary home), using the wrong household size, or failing to apply the $20 income disregard correctly.

Your Right to a Fair Hearing

Under 42 CFR Part 431 Subpart E and Montana administrative regulations, you have 90 calendar days from the date printed on the Notice of Adverse Action to request a fair hearing through the DPHHS Office of Administrative Hearings.

But the critical deadline is much shorter: to keep your existing benefits running while the appeal is pending, file the hearing request within 10 calendar days of the notice date, or before the effective date of the adverse action. You can still request a hearing within the 90-day period, but filing after the continuation deadline may not keep existing benefits in place during the appeal.

This matters most for existing enrollees whose coverage is being terminated at renewal. New applicants who were denied don't have existing benefits to protect, so the 90-day window is the one that counts for them.

How to File a Hearing Request

The Notice of Decision includes a hearing request form. Send the written request to the DPHHS Office of Administrative Hearings, using the address and any alternate submission instructions listed on your notice.

Include a brief explanation of why you believe the decision is wrong. If the issue is an income calculation error, attach your own math showing the correct disregard application. If the issue is a resource miscount, provide documentation showing the asset is exempt (a property deed for your home, a vehicle title for your primary car, or an irrevocable burial trust agreement).

What Happens at the Hearing

The Office of Administrative Hearings schedules a hearing — typically by phone — with an administrative law judge. You can present evidence, bring a representative (a family member, Montana SHIP counselor, or Montana Legal Services Association attorney), and cross-examine the DPHHS worker who made the decision.

Hearings are fact-based. The judge reviews whether DPHHS correctly applied the eligibility rules to your specific financial situation. If the agency miscounted income or failed to apply a disregard, the judge can reverse the denial.

Getting Help With Appeals

Montana SHIP (1-800-551-3191) can explain your options and help you understand the notice, though they typically don't represent clients in hearings.

Montana Legal Services Association (1-800-666-6124) provides legal representation to low-income Montanans in Medicaid fair hearings. Staffing is limited, so call as soon as you decide to appeal.

Common Reversal Scenarios

• Income was counted wrong. The $20 unearned income disregard wasn't applied. Earned income disregards were missed. Spousal deeming allocations weren't calculated.
• Assets were misclassified. A primary residence was counted. A single vehicle was treated as a countable resource. Life insurance under $1,500 face value was included.
• Household composition error. Adult children's income was deemed to the parent. A separated spouse's income was still being counted.

For hearing request templates and step-by-step appeal preparation, see the Montana Medicare Savings Programs guide.

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