A fundamental attribute of health insurance is the existence of enforceable protections to ensure that applicants will get coverage if they meet the eligibility requirements and enrollees with coverage will receive medically necessary services within their benefits package. Beneficiaries' ability to contest an adverse determination is a basic right recognized by law in all types of health insurance, including private insurance, Medicare, and insurance available to federal employees and members of the military, as well as Medicaid. The Medicaid appeals process, however, is different from the appeals processes available through the Medicare program and private health insurance. The Medicaid program is a vital source of health insurance for nearly 60 million people with low incomes, people with disabilities, and seniors. But, none of the services offered by the Medicaid program are meaningful unless people who are eligible are able to enroll and, once enrolled, can access covered services. Given the number of beneficiaries and the constant fiscal pressure for cost containment, it is inevitable that sometimes coverage is denied and mistakes are made. Resolving these issues fairly and expeditiously is critical to the Medicaid program's ability to achieve its coverage goals. Due to the nature of the program, Medicaid appeal rights have both constitutional and statutory underpinnings. This background paper describes the appeals system available to Medicaid applicants and beneficiaries, including the fair hearing process and the appeals process required for Medicaid managed care organizations (MCOs).
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