Pennsylvania Medicaid Appeal: How to Fight a Long-Term Care Denial
Why Medicaid Applications Get Denied in Pennsylvania
A denial letter from the County Assistance Office doesn't mean your parent can't qualify. It means something in the application didn't satisfy the caseworker's requirements — and in many cases, that something is fixable.
The most common denial reasons for long-term care Medicaid in Pennsylvania:
Excess resources. The parent's countable assets exceed the limit. For applicants with gross monthly income at or below $2,982, the limit is $8,000. For those with income above $2,982, it drops to $2,400. Families frequently miscalculate because they don't know which assets are countable (checking accounts, savings, stocks, bonds, non-primary real estate) versus exempt (the primary home up to $752,000 equity, one vehicle, irrevocable burial funds, household goods).
Excess income. The parent's gross monthly income exceeds the $2,982 Special Income Limit. Note that the County Assistance Office evaluates gross income — before tax withholding and Medicare premium deductions — which is higher than what appears on bank deposit statements.
Verification failure. The caseworker requested additional documentation (bank statements, property deeds, income verification) and the family didn't provide it within the deadline. This is the most frustrating denial because the parent may be fully eligible, but the case closed on a technicality.
Transfer penalty. The five-year lookback review found uncompensated transfers — gifts, below-market-value sales, or asset movements — within the 60-month window.
Clinical ineligibility. The functional assessment determined the parent does not meet the Nursing Facility Clinically Eligible (NFCE) standard required for nursing home Medicaid or the Community HealthChoices waiver.
Your Right to a Fair Hearing
Pennsylvania provides a fair-hearing process for Medicaid denials, reductions, and terminations through the Bureau of Hearings and Appeals within the Department of Human Services. A fair hearing is an administrative proceeding where a hearing officer reviews the County Assistance Office's decision.
The 30-day deadline is firm. You have 30 calendar days from the date on the denial notice to file your appeal. If you miss this deadline, you lose the right to challenge that specific decision. The clock starts from the notice date, not when you received it.
File immediately, even if you're gathering documents. You don't need to have your entire argument ready when you file. The appeal preserves your right to a hearing while you assemble evidence. Filing also triggers "aid paid pending" protections if services are being reduced or terminated (more on this below).
How to File
Follow the instructions on the denial notice. For most Medicaid recipient appeals, submit a written request to the DHS office or County Assistance Office that made the decision; the notice states the correct destination, method, and deadline. If you have questions about filing, use the phone number listed on the notice.
The appeal should identify the specific decision being challenged, state why you believe the decision was wrong, and include any supporting documentation that wasn't part of the original application.
Free Download
Get the Pennsylvania — Medicaid Long-Term Care Eligibility Checklist
Everything in this article as a printable checklist — plus action plans and reference guides you can start using today.
Aid Paid Pending: Keeping Coverage During Appeal
If your parent is already receiving Medicaid-funded long-term care and the County Assistance Office issues a notice reducing or terminating coverage, filing an appeal within 10 days of the notice date (not 30) triggers "aid paid pending" status. This means the current level of benefits continues unchanged until the hearing officer issues a final decision.
This protection is critical in nursing home situations. Without it, the facility would start billing privately on the effective date of the termination — potentially thousands of dollars per month while the appeal is being resolved.
Aid paid pending does not apply to initial application denials, only to reductions or terminations of existing coverage.
What Happens at the Hearing
Fair hearings are typically conducted by phone, though in-person hearings can be requested. A hearing officer — an administrative law judge who is independent from the County Assistance Office — reviews the evidence from both sides.
You can represent yourself, bring a family member, or have an attorney or advocate represent you. The Pennsylvania Health Law Project (PHLP) may provide free legal assistance or representation for Medicaid appeals — contact them at 1-800-274-3258.
Bring everything: bank statements, income documentation, medical records, correspondence with the County Assistance Office, and any evidence that directly addresses the denial reason. If the denial was for verification failure, bring the documents the caseworker requested. If it was for excess resources, bring evidence that the assets are exempt or have been properly spent down.
The hearing officer issues a written decision, usually within 90 days. If you win, the written decision will state what coverage or relief is owed.
When Verification Failure Is the Problem
Verification failures account for a disproportionate number of denials, and they're almost always recoverable. The County Assistance Office sends a verification checklist (often requesting 60 months of bank statements, pension award letters, property deeds, vehicle titles, and insurance policies), gives the family a deadline, and closes the case if the documents aren't provided.
If you missed the deadline, your appeal should explain why and include the complete documentation package. Common legitimate reasons: the family was gathering records from multiple financial institutions, the parent was hospitalized and couldn't access their files, or the caseworker's request was mailed to an outdated address.
The faster path is often to file a new application with complete documentation rather than waiting for the appeal to process — but only if the parent's financial situation hasn't changed in a way that would make the new application weaker.
The Pennsylvania Paying for Care Guide includes an Application Document Checklist covering every record the County Assistance Office typically requests, organized by the verification categories they use — so families can compile the package correctly the first time and avoid the verification trap entirely.
Get Your Free Pennsylvania — Medicaid Long-Term Care Eligibility Checklist
Download the Pennsylvania — Medicaid Long-Term Care Eligibility Checklist — a printable guide with checklists, scripts, and action plans you can start using today.