For Parents

Medicaid Appeals and Fair Hearings

It is YOUR RIGHT TO APPEAL decisions of the local social services agency. If you want more information or help with an appeal, you may contact the local social services agency. It will not cost you anything to request a fair hearing, and you will not be penalized for asking for a fair hearing. If you desire free legal advice, you may contact your local legal aid office.

A fair hearing provides you the opportunity to review the way a local social services agency has handled your situation concerning your stated need for Medicaid and Title XXI. The fair hearing is a private, informal meeting at the local social services agency with you and anyone you wish to bring as a witness or to help you tell your story, such as a lawyer. The person who conducts the hearing is someone from the Department of Medical Assistance Services, not someone from your local social services agency. The hearing officer makes a decision on your appeal.

Any denial of Medicaid coverage for a service may be appealed to the Department of Medical Assistance. The appeal must be made in writing by the recipient or legally appointed representaive.

If you wish to request a hearing, the request must be made within 30 days of receipt of the notice of action on your case. The request for a hearing must go to the Department of Medical Assistance Services, 600 East Broad St., Suite 1300, Richmond, Virginia 23219.

You will be notified of the date and time for your hearing at the local social services agency or at a location agreeable to you and the agency. If you cannot be there on that day, call the hearing officer immediately. If you need transportation, the local agency will provide it. You may bring a representative and/or witness to the hearing to help you tell your story. Your eligibility worker, a local agency supervisor, and possible other agency staff who know about your case may also be at the hearing to tell how the agency’s decision was reached.

At the hearing, you and/or your representative will be given the opportunity to:

1. examine all documents and records which are used at the hearing;
2. present your case or have it presented by a lawyer or by another authorized representative;
3. bring witnesses;
4. establish pertinent facts and advance arguments; and
5. question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses.

The decision or recommendation of the hearing officer shall be based exclusively on evidence and other material introduced at the hearing, except when medical information is requested or other essential information is needed. In such an event, you and the local social services agency would be given the opportunity to question or refute this additional information.

You will be notified in writing of the hearing officer’s decision on your appeal within 90 days of the date your appeal request is received by the Department of Medical Assistance Services.