Medicaid Fair Hearings in New York: The 60-Day Rule and the 10-Day Rule

What a fair hearing is, and what it is not

New York runs two separate review systems, and knowing which one you are in saves weeks.

A fair hearing is the state’s own review, conducted by the Office of Temporary and Disability Assistance, of a decision made about your Medicaid eligibility or services. It reaches decisions by the local district or by a managed care plan about Medicaid-covered services.

A plan appeal is an insurance company’s internal review of a coverage denial, followed for commercial coverage by an external appeal through the Department of Financial Services. How that route works.

If you are in a Medicaid managed care plan and the plan denied a service, the usual order is the plan’s internal appeal first, then the fair hearing. If the decision came from the local district, the fair hearing is the route directly.

The two clocks

This is the part worth reading twice, because the consequence of getting it wrong is not losing the appeal. It is losing the service while the appeal is pending.

For someone whose home care hours are being cut, that difference is the difference between care continuing on Monday and care stopping on Monday. The hearing itself may take weeks to schedule.

How to request one

By phone: 800-342-3334. Have the notice in front of you; they will ask for information printed on it.

Online, through the state’s fair hearing request system.

In writing, following the instructions printed on the notice itself.

Whichever route you use, the request should say three things: that you want a fair hearing, that you want aid continuing if you are currently receiving the service, and what decision you are challenging. Keep proof that you sent it and when.

After the request, the Office of Temporary and Disability Assistance mails a scheduling notice with the date, the time and the phone number they will call. Many hearings are held by telephone.

What to bring, and what actually decides it

A fair hearing is not a formality and it is not a trial. It is a hearing officer looking at whether the decision followed the rules on the facts of your case. What moves it:

The notice itself. It states the reason for the decision, and the reason is what you are contesting.

Documentation of your situation. For a home care reduction: a letter from the treating doctor describing what help is needed and what happens without it. For an eligibility denial: the income and residence documents that were submitted, with proof of when. For a spend-down dispute: the calculation you asked the district to provide.

A written account of dates. When you applied, when you sent what, who you spoke to and when. Cases turn on timelines more often than on arguments.

Your own description of a bad day. For anything involving care hours, a plain account of what actually happens without help, at night and on the worst days rather than the average ones, does more work than any adjective.

What the district has to do

At the hearing, the agency that made the decision has to explain the basis for it and produce the evidence it relied on. You are entitled to see your case file before the hearing, and asking for it in advance is a normal request rather than an aggressive one. If the file shows the decision was made on incomplete information, that is frequently the whole case.

Free help, and when to get it

You do not need a representative. Many people go through this successfully alone, especially where the problem is a document that never got matched to the file.

Get help when the stakes are care rather than paperwork: a reduction in home care hours, a termination of long-term care services, a denial after a hospital stay, or anything involving a spouse, a house or a transfer of assets. New York City funds legal services organizations that handle exactly these hearings at no cost, and saying “Medicaid fair hearing” and the date of the notice moves a case up an intake queue.

Where fair hearings come up most

Home care hours reduced at reassessment. The most common, and the most time-sensitive because of aid continuing. CDPAP and how hours are set.

Coverage terminated at renewal. Frequently a mail problem rather than an eligibility problem. Renewals and how they fail.

A spend-down amount that looks wrong. Ask for the calculation in writing first; if it does not resolve, the hearing is the route. How spend-downs are calculated.

An application that never got decided. A decision that never arrives is itself reviewable. You do not have to wait indefinitely.

Long-term care eligibility and the look-back. These are the hearings where a lawyer earns their keep.

If you lose

A fair hearing decision can be challenged further in court, on a shorter clock than the one that got you here. If the decision goes against you and the stakes are ongoing care, that is the point to speak to a legal services organization about the next step rather than starting over with a new application.

And separately from any appeal: if the dispute is about a bill rather than about coverage, New York’s hospital financial assistance law runs on its own track and does not care how the Medicaid question ends.