Medicaid appeals in California: hearing deadline and keeping benefits

Medicaid (Medi-Cal) denials in California

Medicaid agency

California Department of Health Care Services (DHCS) and county social services offices

Who holds the hearing

California Department of Social Services (CDSS), State Hearings Division

Hearing deadline

90 days

The date of the notice of action (the action you disagree with)

If you are late

After 90 days you must show a good reason for filing late, such as illness or a disability. A hearing cannot be granted for good cause more than 180 days after the action.

Temporary rule

For eligibility-related hearings after a Medi-Cal renewal (redetermination), such as an end of Medi-Cal, a cut from full to limited benefits, or a higher share of cost, you have 120 days from the date the notice was mailed. This temporary extension started April 1, 2023 and stays in effect until further notice. It does not apply to new applications or to requests for a particular treatment or service.

How to ask for a hearing

• Online: CDSS online hearing request: acms.dss.ca.gov
• Phone: State Hearings Division, toll-free 1-800-743-8525 (TDD 1-800-952-8349); you can also ask for an expedited hearing by phone
• Mail: California Department of Social Services, State Hearings Division, P.O. Box 944243, Mail Station 9-17-442, Sacramento, California 94244-2430, or to the county welfare department at the address on your notice
• Form: Fill out the "Request for State Hearing" on the back of your Notice of Action

acms.dss.ca.gov · 1-800-743-8525

Mail address

California Department of Social Services, State Hearings Division, P.O. Box 944243, Mail Station 9-17-442, Sacramento, California 94244-2430

What to include

Your full name, address and phone number, the county that took the action, the program involved, and why you want a hearing. Tell them your language (and dialect) if you need an interpreter, and the name and address of any authorized representative. Keep a copy.

Keeping your benefits during the appeal

Your benefits continue while you wait for the hearing (Aid Paid Pending) if you ask for a hearing by the effective date of the change when a 10-day notice is required, or within 10 days of the date of the notice when it is not.

Law: 42 CFR 431.230; Cal. Welf. & Inst. Code 10951

When the hearing is held

The hearing must be set to start within 30 working days after the request, with written notice at least 10 days before.

Law: Cal. Welf. & Inst. Code 10952; Cal. Welf. & Inst. Code 10951

Faster (expedited) hearing

You can ask for an expedited hearing by calling 1-800-743-8525.

Law: Cal. Welf. & Inst. Code 10951

Ombudsman

Medi-Cal Managed Care and Mental Health Office of the Ombudsman · 1-888-452-8609

Medicaid health plan (managed care) in California

Appeal to the plan first

Appeal to your Medi-Cal managed care plan first, within 60 calendar days of the notice of action. The plan must decide within 30 days, or within 72 hours for an expedited appeal. If the plan says no, ask for a state hearing within 120 calendar days of the plan's Notice of Appeal Resolution.

Then a state hearing

120 days

The date of the plan's Notice of Appeal Resolution

Source: the notice that the plan upheld its decision

If the plan is late

If the plan does not decide your appeal within 30 days, you can ask for a state hearing without waiting.

Optional outside medical review

If your Medi-Cal plan is regulated by the DMHC, you may also be able to ask the DMHC for an Independent Medical Review of a medical necessity denial.

Late requests

A late request may be accepted for good cause, but not more than 180 days after the plan's notice.

Law: Cal. Welf. & Inst. Code 10951(b), 14197.3; Cal. Health & Safety Code 1374.30(f); Cal. Health & Safety Code 42 CFR 438.402

Write my appeal: free letters

Letter: Medicaid fair hearing request