The Medicaid half of a dual-eligible appeal: the state fair hearing
Checked against the current rules on September 23, 2026.
A Dual Eligible Special Needs Plan (D-SNP) enrollee has Medicare AND Medicaid. When the plan's combined integrated denial covers both, an unfavorable decision splits into two separate tracks that run at the same time.
Source: 42 CFR Part 438, Subpart F — §§ 438.408, 438.420 (Medicaid managed care appeals).
The Medicare half of the case is forwarded automatically to the Independent Review Entity — the plan has to do this, you don't have to ask.42 CFR 422.634
The Medicaid half works differently: you (or someone you authorize) have to actively request a state fair hearing yourself — it does not happen automatically.42 CFR 422.634
You have at least 90 days, and your state may allow up to 120, from the date of the plan's written decision to request that hearing.42 CFR 438.408
If you want services to keep going during the appeal
Keeping services running during the appeal is a separate, much shorter window than the 90-120 days you have to request the hearing itself — you generally have to act within 10 days of the plan's notice, or by the date the service would otherwise end, whichever is later.42 CFR 438.420
If the final decision doesn't go your way, the state may be able to recover the cost of the Medicaid services you kept receiving while the appeal was pending — this is a real, disclosed risk, not a guaranteed loss, and it's a rule that applies to the Medicaid side specifically.42 CFR 438.420
That recovery risk only starts once the plan's written reconsideration decision is final. Costs of continued services furnished up through that decision — on either the Medicare or the Medicaid side — are not recoverable even if you ultimately lose.42 CFR 422.632
Why two forums instead of one
Medicare and Medicaid are two different federal-state programs with two different appeal structures, even inside a single integrated denial notice. The Medicare side keeps its own existing review chain (the Independent Review Entity, then an Administrative Law Judge). The Medicaid side is a state program, so its own appeal — the fair hearing — is run by the state, not by CMS or its contractors.
You're allowed to pursue both forums for the same underlying situation. If the two forums reach different results, the plan has to follow whichever decision is favorable to you — it can't pick the outcome it likes better.42 CFR 422.634
If your Medicaid services are ending without much warning
Separate from the appeal deadlines above, a plan generally has to send you written notice at least 10 days before a previously approved Medicaid service is reduced, suspended, or ended — a small set of exceptions apply (for example, a signed request to stop services, or a documented change ordered by your own physician).42 CFR 431.211
If a plan acted without giving you that advance notice, and you request a hearing promptly, your state's Medicaid agency is required to reinstate the service and keep it going while the hearing is pending — a real, separate remedy worth raising with your state's fair-hearing office if the notice you got felt rushed or came after the fact.42 CFR 431.231
Sources — last checked September 23, 2026
- 42 CFR 422.632as of September 23, 2026
- 42 CFR 422.634as of September 23, 2026
- 42 CFR 431.211as of September 23, 2026
- 42 CFR 431.231as of September 23, 2026
- 42 CFR 438.408as of September 23, 2026
- 42 CFR 438.420as of September 23, 2026
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
