Medicaid appeals in Florida: hearing deadline and keeping benefits

Medicaid (Florida Medicaid (Statewide Medicaid Managed Care, SMMC)) denials in Florida

Medicaid agency

Agency for Health Care Administration (AHCA) runs Medicaid services; the Department of Children and Families (DCF) decides Medicaid financial eligibility

Who holds the hearing

For denied, reduced or stopped services: AHCA Office of Fair Hearings (Medicaid Hearing Unit). For Medicaid eligibility decisions by DCF: DCF Office of Inspector General, Appeal Hearings Section

Hearing deadline

90 days

The date on the written notice (if the notice was mailed later than its date, from the mailing date). For AHCA service decisions, the request must be received within 90 days of the date the notice was sent.

If you are late

The time limit does not apply if DCF failed to send a required notice, failed to act on a specific request, or denied a request without telling you. For service decisions, AHCA may waive the 90-day limit if it failed to send a timely notice or failed to act on your specific request for benefits.

How to ask for a hearing

• Online: DCF eligibility decisions: online form at www.myflfamilies.com/fairhearings/
• Phone: DCF eligibility decisions: Appeal Hearings Section (850) 488-1429, or a local DCF office or the Customer Call Center. Medicaid service decisions: Medicaid Helpline 1-877-254-1055 (TDD 1-866-467-4970)
• Mail: DCF eligibility: Appeal Hearings Section, 2415 North Monroe Street, Suite 400-I, Tallahassee, Florida 32303-4190. Medicaid services: Agency for Health Care Administration, Medicaid Hearing Unit, P.O. Box 7237, Tallahassee, Florida 32314-7237
• Email: DCF eligibility: appeal.hearings@myflfamilies.com. Medicaid services: MedicaidHearingUnit@ahca.myflorida.com (replies come encrypted)
• Fax: Medicaid services: (239) 338-2642

www.myflfamilies.com · (850) 488-1429

Mail address

Appeal Hearings Section, 2415 North Monroe Street, Suite 400-I, Tallahassee, Florida 32303-4190

What to include

For a Medicaid service hearing: your name, phone number, mailing address and email (if any), the name and Medicaid ID number of the person the hearing is for, some details about the services that were denied, reduced or stopped, any related notices, and whether you want to be contacted by mail or email. For DCF eligibility hearings, follow the instructions that came with your notice.

Keeping your benefits during the appeal

For DCF Medicaid eligibility actions, your assistance continues at the current level until the hearing decision if you ask for a hearing (orally or in writing) within 10 days after the notice was mailed or handed to you. For Medicaid plan service cuts, see the managed care rule.

Law: Fla. Admin. Code R. 65-2.048(1); Fla. Admin. Code R. 65-2.046, 65-2.048 (DCF); R. 59G-1.100 (AHCA Medicaid Fair Hearings)

When the hearing is held

DCF issues a written Final Order within federal time limits counted from when the request was received: 90 days for Medicaid. AHCA's hearing officer must issue a Final Order within 90 days of the hearing request unless you waive it or it is extended, and sends a notice of hearing at least 14 days ahead. Most hearings are by phone, but you have a right to an in-person hearing.

Law: Fla. Admin. Code R. 59G-1.100(10), (18); Fla. Admin. Code R. 65-2.046, 65-2.048 (DCF); R. 59G-1.100 (AHCA Medicaid Fair Hearings)

Faster (expedited) hearing

AHCA holds expedited fair hearings for Medicaid service decisions; in an expedited hearing your case file must be given to you within 24 hours of your request. Ask for an expedited hearing when you call or write the Medicaid Hearing Unit.

Law: Fla. Admin. Code R. 65-2.046, 65-2.048 (DCF); R. 59G-1.100 (AHCA Medicaid Fair Hearings)

Medicaid health plan (managed care) in Florida

Appeal to the plan first

If you are in a Medicaid health or dental plan, you must finish the plan's appeal process before a fair hearing; a hearing request made too early may be turned down. Ask the plan for an appeal within 60 days of the notice of adverse benefit determination. The plan must decide within 30 days, or within 48 hours for an expedited appeal when waiting could harm you. If the plan upholds any part of its decision, ask AHCA for a Medicaid fair hearing within 120 days; a hearing officer decides in about 90 days. To keep a service that is being reduced, stopped or suspended, file the appeal or hearing request within 10 days after the notice was mailed or on or before the day the change starts. If you lose, you may be asked to pay for those services, but Medicaid benefits cannot be taken away if you cannot pay, and your family cannot be asked to pay.

Then a state hearing

120 days

The date the plan's Notice of Plan Appeal Resolution was sent (the request must be received by AHCA within 120 days)

If the plan is late

If the plan does not follow the federal notice and timing rules for plan appeals, the plan appeal counts as complete and you can ask for a fair hearing.

Law: Fla. Admin. Code R. 59G-1.100(8)(e)-(g); Process for Enrollee Grievances and Appeals (12/4/2024)

Write my appeal: free letters

Letter: Medicaid fair hearing request