If you have a disagreement with Medi-Cal regarding your child’s care, you are entitled to due process, which means that you have the right to have a fair and impartial decision-maker hear your arguments and give a ruling based on program laws and regulations and the facts of the case. This article aims to help you understand the Medi-Cal appeal process and get an idea of what to expect as you advocate for your child’s care.
Note that this article is for informational purposes only and is not intended to provide legal advice. If you are seeking legal advice or representation, we recommend that you consult with an attorney who can assist you with the appeal process.
Before you dive into the appeal process itself, it’s important to have a basic understanding of some of the terms you’ll come across in your advocacy. Below are some of the terms you’ll see most often when dealing with Medi-Cal, especially at the appeal level.
A Notice of Action (NOA) is a written notice providing an explanation of eligibility, coverage, or benefits to Medi-Cal applicants and beneficiaries. An NOA includes the decision and effective date of coverage as well as any changes made in eligibility status or level of benefits. If the NOA is denying or terminating a benefit, it should provide a reason for the denial or termination. It also includes information about hearing rights and how to appeal the decision if you disagree with the determination. Sometimes a denial or termination notice from a managed care plan is called a “Notice of Adverse Benefit Determination” or just an “Adverse Benefit Determination” (ABD) instead of a “Notice of Action.” [1] If you don’t understand your NOA or have questions about your eligibility, you can contact your local county office (or your managed care plan, if that’s who sent the notice) at the phone number listed on the NOA. You may also find county contact information on your Local County Office website.
Note: Most NOAs come in the form of a letter and are fairly straightforward. An IHSS NOA can be more complicated and confusing because it’s a large grid of numbers with little explanation. For a visual walkthrough of an IHSS NOA, see this video explanation from Undivided Public Benefits Specialist Lisa Concoff Kronbeck.
If you receive an NOA reducing or terminating a benefit or service that you are already receiving (including Medi-Cal eligibility itself), in most cases you can continue to receive the benefit during the appeal process if you appeal within ten calendar days of receiving the NOA. You should submit the appeal request (this includes managed care grievances) in writing so that there is proof it was completed, and you may also wish to make a note on the appeal form or in your written request that you are requesting aid paid pending appeal. [2] For an adverse decision by a managed health care plan, the deadline to request aid paid pending appeal is either within ten days of the date the NOA was sent, or on or before the proposed service termination date, whichever is later. [3] Still, to avoid delays in the appeal process and ensure that your child receives aid paid pending appeal, it’s generally best to get your written appeal request submitted as soon as possible.
A grievance is a formal complaint that you file with your Medi-Cal managed care plan when you are having trouble getting medically necessary services or care for your child. [4] For disputes with the managed care plan over issues pertaining to your child’s care, you must submit a grievance and receive a decision from the managed care plan before you can request a state hearing.
The Department of Managed Health Care regulates most managed care plans in California, with the exception of a few county-operated health systems. Members whose plans are subject to DMHC oversight may have some additional appeal options aside from or in addition to a state hearing. These include an independent medical review and a consumer complaint, both of which will be discussed in detail below.
A state hearing (also sometimes called a fair hearing), is an administrative proceeding where you and the state, county, or managed care plan have a chance to present the issue in dispute, submit evidence in support of your position, and receive a decision from an impartial hearing officer known as an Administrative Law Judge (ALJ). A state hearing is a legal proceeding, but the rules are not quite as stringent as they are in a civil or criminal court. While many families choose to hire an attorney or advocate, the process is designed for individuals and families to be able to self-advocate.
The Office of the Ombudsman may be able to assist with enrollment problems or other issues with the managed care plan. They may also be able to connect you to the correct person at your plan or in your county who can assist you. The Office of the Ombudsman is not a replacement for the appeal process, but they may be able to assist with issues that would not typically be addressed at appeal (e.g. accidental enrollment or disenrollment from a managed care plan or fee-for-service Medi-Cal).
As you can see from reviewing the terms above, there are multiple ways to dispute a Medi-Cal decision depending on the type of conflict you are experiencing. Your first steps depend on what type of dispute you have.
Here are some examples of types of disputes and how to initiate the appeal process:
Initial determination of Medi-Cal ineligibility → File a state hearing request.
Termination of existing Medi-Cal coverage → File a state hearing request (in writing, within ten days, for aid paid pending appeal).
Plan enrollment issues → Contact the plan or Health Care Options and/or the Ombudsman’s office, then file a state hearing request if they cannot resolve the issue or point you in the right direction.
Disputes over medical necessity, coverage, providers, access to care, etc. with a managed care plan → File a grievance with managed care plan.
Disputes over medical necessity, coverage, providers, access to care, etc. with fee for service Medi-Cal → File a state hearing request.
IHSS disputes → File a state hearing request.
No matter your dispute, here are some words of advice to keep in mind for your appeal:
When you disagree with your Medi-Cal managed care plan over issues of medical necessity, coverage, providers, or access to care more broadly (for example, if all of the contracted providers have a long waiting list), you should file a grievance with your managed care plan within 60 days of the Notice of Action. Again, if you are asking for aid paid pending appeal, the deadline for filing a grievance will be shorter (either within ten days of the date the NOA was sent, or on or before the proposed service termination date, whichever is later. [5])
Contact your managed care plan’s member services department to begin the grievance process. Grievances can be filed over the phone or in writing (do this in writing if you want aid paid pending appeal, either by fax or mail). Typically, a few days later, you will receive a letter from the managed care plan confirming that they have received your grievance. You may be invited to contact a case manager with further information, or they may reach out to you by phone. From the time you submit your grievance, the plan has 30 days to issue a decision, or 3 days if the grievance is about an urgent medical issue.
If the medical issue is urgent, be sure that you mention this at the time you file the grievance, and explicitly request expedited review. Do not assume that the managed care plan will know that the medical issue is urgent.
For detailed information about appealing managed care decisions, please see All-Plan Letter 21-011.
NOTE: You must exhaust your appeal rights within the managed care plan by filing a grievance and receiving a decision before you can appeal at a higher level, e.g. a state hearing.
However, there is one exception to this rule: “deemed exhaustion.” For most Medi-Cal managed care plans, you may file a request for state hearing immediately if your plan did not notify you in a timely manner regarding your benefits. DHCS’s publication on appeal rights under Medi-Cal managed care gives the following examples that constitute deemed exhaustion:
In these limited situations, you can skip the grievance process and escalate your request for appeal immediately.
If you disagree with the outcome of the decision, you have a few different options depending on your county and which managed care plan you have. Regardless of your plan or county of residence, you can file a request for a state hearing once you receive an adverse grievance decision.
Most managed care plans are also subject to additional review procedures by the Department of Managed Health Care (DMHC), which regulates health plans subject to the Knox-Keene Act, a set of laws governing the operation of managed health care plans in California. However, some counties operate a single managed care option called a County Operated Health System (COHS), which is not subject to the Knox-Keene Act. In these counties, you cannot request help from DMHC, and you should just file a request for state hearing. According to Disability Rights California (DRC), these plans include:
If your plan is subject to regulation by DMHC, you have two options: ask for help from DMHC or request a state hearing.
Four factors that may help you decide which route to take:
If you start with DMHC and disagree with their decision, you can still request a state hearing if the deadline hasn’t yet passed. However, if you go to a state hearing first and disagree with the decision, you cannot go back and ask for help from DMHC. This means that you may want to give serious consideration to which process is most appropriate for you, and perhaps discuss with an attorney or advocate. It may be encouraging to know that you can still request a state hearing if you disagree with the IMR or Complaint, but be aware that at hearing, the state-level Independent Medical Review may carry more weight than the plan-level grievance decision if either you or the plan submits it to the ALJ.
If you request a state hearing, you can potentially get aid paid pending appeal. There is no aid paid pending appeal with the DMHC process. If you need existing services to continue during the appeal process, you should keep this in mind when deciding how to proceed.
Medi-Cal managed care members have 120 days following thea NOA to request a state hearing. This clock is running while you are filing a grievance and waiting for a decision, and it keeps running if you decide to ask for help from DMHC. So if you disagree with DMHC’s decision, you now have a much shorter window to request a hearing and should stay on top of the deadlines.
The timeline for asking DMHC for help is longer than the timeline for requesting a state hearing, so if your deadline for asking for a state hearing has already passed, you may still be able to get help from DMHC.
For further reading, review Disability Rights California’s publication on Independent Medical Reviews, which has a section on deciding whether to seek help from DMHC or request a state hearing.
Any California managed care plan participant (whether on a private plan or Medi-Cal plan) may submit a request to the Department of Managed Health Care (DMHC) for a state-level independent medical review (IMR) or consumer complaint, aside from the excluded county-run health systems discussed above. These requests may only be submitted after you have filed a grievance with your managed care plan and disagree with the outcome. You have 180 days (six months) from the date of the adverse grievance decision to request an IMR or file a complaint. DMHC reports that approximately 68% of patients receive the requested service through this process.
According to DHMC’s complaint website, an IMR is appropriate when a health plan “denies, changes, or delays your request for medical services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment for a serious medical condition.”
A consumer complaint addresses other issues, such as “billing problems, cancellation of coverage, claim and copay disputes, delays in getting an appointment, referral or authorization, access to translation services, finding an in-network doctor, hospital, or specialist, [and] complaints about a doctor or plan and continuity of care.”
The same form is used both to request an IMR and to file a consumer complaint; based on the circumstances, DMHC will determine whether this should be treated as an IMR request or a complaint.
Requests for IMR and Consumer Complaints can be submitted online, faxed, or mailed. The form is available on the Department of Managed Health Care’s website for IMRs and Complaints, under “How to Apply.” Typically, requests for urgent matters are decided within seven days, and non-urgent matters are decided within 45 days for IMRs and 30 days for Consumer Complaints. Again, you should indicate on your form when a matter is urgent.
For participants in a private health care plan, the IMR/Complaint process is the final administrative appeal level. Per DMHC’s Frequently Asked Questions, “If the complaint is not decided in your favor, you cannot appeal the decision. However, you may still be able to take legal action and may want to speak with a private attorney.”
However, for Medi-Cal recipients, a state hearing provides an additional administrative appeal level.
If you disagree with a Medi-Cal Notice of Action, you can request a state hearing (this is sometimes also called a fair hearing).
The California Department of Social Services offers multiple methods for submitting a state hearing request. You can request a hearing online; you have the option to create an account or submit without an account, but creating an account will make tracking easier. You can request a fair hearing by phone at (800) 743-8525. You may also fill out the Request for State Hearing form included with your Notice of Action (NOA) and mail it to:
California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430
You can also fax to (833) 281-0905.
The request must be filed within 90 days of receiving the NOA if the dispute is with your county or the CA Department of Health Care Services (usually for issues relating to Medi-Cal eligibility or IHSS), or within 120 days if the dispute is with your managed care plan (usually relating to coverage for specific care, services, providers, etc.).
Again, if your child is enrolled in a Medi-Cal managed care plan, you must exhaust your appeal rights with the managed care plan before filing for a state hearing. This is why the state hearing deadline is extended for disputes with the managed care plan: the state gives you additional time to file a grievance and possibly even a DMHC complaint and wait for the decision before pursuing a state hearing.
You may be able to file a late hearing request if you have a compelling reason, such as illness or disability, and the statutory deadlines may also be extended during periods of public emergency (e.g. during the COVID-19 pandemic).
Most CDSS hearings take place over the phone unless you request an in-person or remote video hearing. You can indicate your preference on the appeal form. If no preference is specified, CDSS will default to a phone hearing. When you submit your request for hearing, you will also indicate whether you need any interpretation services or disability accommodations, and whether your issue is urgent and may necessitate expedited review (see below).
All state hearings need to be decided within 90 days of the hearing request, unless you have waived that requirement. [6] If you believe that waiting this long may be harmful to your child’s health, you may be able to request an expedited hearing, in which case your decision must be issued within three days. You may need to submit documentation as to why you cannot wait 90 days for a decision. You ask for an expedited hearing and submit any related documentation at the time you submit your request for state hearing.
For more information on how to request a fair hearing, see the DHCS website. Side note: The different agencies can be a bit confusing; Medi-Cal is operated by DHCS, but DHCS contracts with the CA Department of Social Services to oversee the state hearings process. [7]
You should receive a written notice of your hearing date and time from the California Department of Social Services State Hearings Division (SHD) at least ten days before the hearing is scheduled. If you are unavailable during the designated hearing time, let the hearing office know immediately, in writing, that you’d like to request a different date, and provide some alternatives if possible. You can postpone the hearing up to 30 days. Beyond that, you should also contact SHD in writing, and SHD will determine whether you have good cause to reschedule. [8] Your notice of hearing should include contact information for your particular hearing office branch. You can also call the State Hearings Division at 800-743-8525 to inquire about the appropriate place to send communications and evidence.
The request for state hearing includes questions about whether you require disability accommodations or language interpretation services, including ASL. You need to request accommodations and/or interpretation prior to the hearing, and the initial request for hearing is the best time to make those requests. You can also notify SHD in writing prior to the hearing — the further in advance, the better.
Additionally, you are entitled to a competent interpreter. [9] If you arrive at the hearing and your interpreter is unable to translate adequately, you have the right to request that the hearing be continued until a competent interpreter can be provided. Some advocates suggest that you bring a friend or family member to the hearing who is fluent in both languages so they can flag any translation problems for you. Similarly, if you arrive and the hearing is inaccessible to you as a person with disabilities despite requesting accommodations, you have the right to request a continuance. [10]
Legal argument: As Disability Rights CA explains in a related publication about Regional Center hearings, “Your legal argument is the law you are relying on to show you qualify for the service you and [the agency] disagree about, and the facts that support your claim.” To prepare your legal argument for a state hearing, you should review the law supporting your position. For an Independent Medical Review, you should not need to present a legal argument. For both types of appeals, you will also want to focus on medical necessity.
Documentation: For both a state hearing and an IMR, you will need to present thorough and detailed documentation of medical necessity if the case centers on a specific treatment. These should come from medical providers who are familiar with your child’s condition and treatment and can articulate why the specific treatment you are requesting is medically necessary, and, if applicable, why the condition cannot be treated adequately with the approach that the plan is offering. You should gather any written documentation that supports your claim, including but not limited to assessments and reports, treatment notes, declarations (sworn statements of fact that are signed under oath), and other medical records. You may also submit a position statement detailing your arguments and outlining the medical record.
Witnesses: You can have people submit letters or declarations in support of your position and/or testify at the hearing. Disability Rights CA suggests in their Regional Center hearing packet that a judge might give more weight to testimony that is given in person in the hearing. The same may be true of Medi-Cal hearings, particularly as it gives the judge an opportunity to ask clarifying questions.
Evidence exchange: For a state hearing, the opposing county or state agency (depending on the hearing issue) is required to provide you with its position statement (a document articulating its position and arguments) at least two working days before the scheduled hearing. If you have not received the position statement two days before the hearing, it might be helpful to call your appeal worker and request that it be faxed same-day. If the day of the hearing arrives and you have not yet received the position statement, you can request a continuance. [11] You should submit your own documentation and position statement to the hearing office at least two working days in advance of the hearing. If evidence is not obtainable by the time of hearing or if the need for further evidence becomes apparent at the hearing, in some cases the judge may be willing to leave the record open for up to 30 days so additional evidence can be submitted. It may be helpful to organize your evidence in date order or otherwise make it easy for the ALJ to quickly refer to specific portions of the documentation. You also have the right to review your case file prior to the hearing, particularly for IHSS-related appeals, where there may be internal documents you don’t usually receive, such as the social worker’s notes or assessments or the specific policies the county is relying upon.
The hearing will be presided over by an administrative law judge, or ALJ. Although this is a formal hearing before a judge, and it will result in a legally binding written decision, the hearing may look more like a work meeting than the “court” setting you might imagine. You might find yourself on a conference call, a Zoom meeting, or just sitting around a conference room table with the ALJ and the county or state agency appeal worker. The ALJ will audio-record the hearing for their reference, and may ask you questions throughout the hearing. ALJs know that parents are not lawyers, and hearings are generally not bound by the strict rules of evidence that apply in court. The process is intended to be accessible to families who are representing themselves. That being said, this is a real judge, so be sure to conduct yourself accordingly.
Opening statement: You will be invited to give an opening statement after the appeal worker gives theirs. In your opening statement, you should tell the ALJ about the issue being disputed, and explain the law that supports your request.
Questioning witnesses: If your hearing has witnesses, the county’s witnesses will testify first. You will have the opportunity to ask questions of the county’s witnesses. Then, your witnesses will testify. You should prepare questions ahead of time, both for your own witnesses and the county’s witnesses. Review DRC’s fair hearing packet, Chapters 3 and 4, for tips on direct- and cross-examination of witnesses as well as preparing for hearing more generally. Although this publication concerns Regional Center hearings, a lot of the preparation and procedures are the same.
Closing statement: You can offer a closing statement at the end of the hearing, or you and the county can agree to submit written closing statements. If you feel there is additional documentary evidence that needs to be submitted and considered, you can ask for the record to be kept open. The ALJ can agree or disagree to this request.
As noted above, all state hearings need to be decided within 90 days of the hearing request, unless you have waived that requirement. [12] For example, if you request a continuance of the hearing, the timeline will be extended to account for the postponement. [13]
If you disagree with the ALJ’s decision, you may wish to consult an attorney if you are not already working with one. Upon receiving the decision, you have 30 days to request a rehearing [14] and one year to request that the matter be heard in your county’s superior court [15].
[1] They are functionally the same document, but federal statutes recently updated the terminology required in managed care decisions, so some terminology had to be revised at the state level.
[2] 22 CCR 51014.2
[3] 42 CFR 438.420
[4] State of California Office of the Patient Advocate, Medi-Cal Complaints
[5] 42 CFR 438.420
[6] MPP § 22-060
[7] Cal Welf & Inst Code § 10950
[8] MPP § 22-053.11; 7 C.F.R. § 273.15(c)(4)
[9] MPP § 22-049.6 et seq.
[10] MPP § 22-053.113
[11] MPP § 22-053.113
[12] MPP § 22-060
[13] 7 C.F.R. § 273.15(c)(4)
[14] CA Welf & Inst Code § 10960
[15] CA Welf & Inst Code § 10962
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