As part of the constitutional right to due process, states must provide an avenue for beneficiaries to appeal adverse decisions concerning their fee-for-service (FFS) and managed care Medicaid benefits. Each state’s hearing system must meet due process standards set forth in the U.S. Supreme Court’s 1970 decision in Goldberg v. Kelly and must be accessible to people who have limited English proficiency and those with disabilities. However, each state retains some flexibility in designing and implementing its process for appeals.
This fact sheet describes the steps each state Medicaid program must take in carrying out its appeals processes for FFS and managed care benefit determinations. Medicaid’s FFS appeals process is described in greater detail in MACPAC’s state policy compendium, Elements of the Medicaid Appeals Process under Fee for Service, by State.
From: Federal Requirements and State Options: How states exercise flexibility under a Medicaid state plan