Medicaid Denial Appeal: The Fair Hearing Deadline by State

You have the right to request a fair hearing. That sentence is on every Medicaid denial in the country, and it is there because a federal regulation orders the state to print it. What the sentence never explains is the part families get wrong: which day the count starts on, which of the two clocks in the same envelope is the one that matters, and why someone in the next state got a different number of days for an identical denial.

The number is not national. It is capped nationally. 42 CFR 431.221(d) tells the state to allow "a reasonable time, not to exceed 90 days from the date that notice of action is mailed" — a ceiling, and states are free to build well under it. Pennsylvania builds much lower. Under 55 Pa. Code § 275.3(b)(1), an appeal must be filed within 30 days of the date of the written notice, and the sentence introducing that subsection warns that appeals missing the limits "will be dismissed without a hearing." New York gives 60. Texas, Florida and California give 90, and start counting on three different days.

So the first useful act is not reading the reasons. It is finding the deadline sentence, working out what calendar date it lands on, and writing that date on the envelope in pen. Everything below is about doing that correctly, and then about the second clock — the earlier one — that decides whether anything keeps being paid while the argument runs.

Every federal citation here was read on 9 September 2026 through the eCFR versioner API, against the title 42 text issued 13 August 2026 — the latest issue date, which eCFR reports as current through 4 September 2026. The state rules and the 2026 dollar figures were read the same day, from the pages listed at the end.

Five things the notice must contain, and the one usually missing

The federal spine for all of this is 42 CFR part 431, subpart E. It binds the state Medicaid agency, and it applies whether the denial is about eligibility, about a benefit, or about a facility's decision to move someone out.

42 CFR 431.206(b) says the agency must inform the applicant or beneficiary in writing of the right to a fair hearing and to an expedited one, the method of obtaining a hearing, the right to be represented by "legal counsel, a relative, a friend, or other spokesman," and the timeframes in which the agency must take final administrative action. Paragraph (c) fixes when that information has to arrive: at the time of application, at the time the agency denies a claim for eligibility, benefits or services, at the time a nursing facility notifies a resident of transfer or discharge, and at the time of an adverse PASRR determination.

The content requirement is 42 CFR 431.210. Five elements — and it is worth ticking them off against the page rather than reading the page for tone.

Element (c) is the one that goes missing. A notice can say "excess resources" and stop, and it will still go in the mail. It is not a complete notice when it does that, and the gap matters later: under 42 CFR 431.244(d) the hearing decision itself has to identify the regulations supporting it, so somebody eventually has to name the rule. Better that it happens while there is still time to go and read it.

42 CFR 435.917(b)(2) closes the loop from the eligibility side: any notice of denial, termination or suspension of Medicaid eligibility "must be consistent with § 431.210." One rule, reached from two directions.

Timing has its own rule. 42 CFR 431.211 requires the notice at least 10 days before the date of action. 431.213 sets out eight exceptions that let the agency send it no later than the date of action; the ones that turn up in eldercare are confirmed death, a signed statement from the beneficiary, admission to an institution where they are ineligible for further services, acceptance for Medicaid in another jurisdiction, and, notably for eldercare, "a change in the level of medical care is prescribed by the beneficiary's physician." 431.214 allows 5 days instead of 10 where the agency has verified facts indicating probable fraud. Those exceptions shorten the advance notice. None of them shortens the time to file.

The 90 days in the federal rule is a ceiling. Your state built under it.

Here is the same question answered by five states, each taken from its own rule rather than from a summary page.

Read the third column twice. Texas takes the later of two dates, which quietly gives more room than the federal ceiling appears to allow when an action takes effect weeks after the letter went out. Florida takes the day after the printed date, then adds a fix for a very ordinary failure: under 65-2.046(2), "if the notice is not mailed on the day it is dated, the time period commences on the date it is mailed." The postmark, if the envelope survived, is evidence.

The sentence immediately before that one in the same paragraph is the larger provision and the easier one to miss. Florida's time limit "does not apply when the Department fails to send a required notification, fails to take action of a specific request or denies a request without informing the appellant." Three situations, each turning on something the agency failed to do, and in none of them does the 90-day count govern.

Each of the other four has its own way out, and the four are not alike.

Pennsylvania's is the most generous and the least known. § 275.3(b)(2) gives 60 days rather than 30 where no written notice was sent because none was required, or where the complaint is a failure to act at all. And (b)(3) says that where the agency failed to send a notice it was required to send, or where administrative error, ongoing delay, or failure to take corrective action is the reason nothing happened, the limits in (b)(2) and (b)(4) do not apply: the client has six months to appeal in writing, and after six months may still file with an affidavit stating that they did not know of the right of appeal or believed the problem was being resolved administratively, that they believe the county office erred, and that the appeal is made in good faith.

California's is statutory. Welfare and Institutions Code § 10951(a)(2) allows a late request where there is good cause, with a hard stop: the department "shall not grant a request for a hearing for good cause if the request is filed more than 180 days after the order or action complained of." Subdivision (c) defines the term, and defines one thing out of it. Good cause means "a substantial and compelling reason beyond the party's control, considering the length of the delay, the diligence of the party making the request, and the potential prejudice to the other party" — and "the inability of a person to understand an adequate and language-compliant notice, in and of itself, shall not constitute good cause."

California also has a longer deadline running alongside the statutory 90, and it applies to exactly the case this page is about most often. CDSS states on its hearing requests page that DHCS received CMS approval to extend the window for redetermination eligibility-related fair hearing requests — terminations of Medi-Cal eligibility, reductions from full to limited benefits, and increases in beneficiary liability or share of cost — to 120 days from the date the notice of action is mailed, effective 1 April 2023 and remaining in effect until further notice. The page is equally clear about the boundary: the extension "does not apply to new Medi-Cal applications," medical exemption requests, or hearing requests about a particular treatment or service. So an initial long-term care application denial is a 90-day case and a termination of existing Medi-Cal is a 120-day case, and the notice will not distinguish them for you.

Texas hands the question to the adjudicator rather than to the caseworker. The state's Fair and Fraud Hearings Handbook, section 1420, revision 25-3 effective 15 May 2025, instructs staff in flat terms: agency staff "may not prevent a client from filing an appeal because staff believe that the appeal was not requested within the required number of calendar days," and "the hearings officer is the final authority on the timeliness of filed appeals." If a Texas office says on the phone that it is too late, that office is not the one who decides.

The same section sets out what the hearings officer does with a late filing: it says the officer "may accept appeals filed after the time limit to determine if there was good cause for the delay in filing," and handbook section 1430, revision 23-1, effective 31 July 2023, turns that into a duty — where an appeal arrives after 90 days, the hearings officer "must determine if the appellant had good cause for failing to appeal timely," at a pre-hearing conference or at the start of the hearing itself. The handbook is candid about the other outcome too: if good cause is not established, "the person has forfeited the right to a fair hearing and the agency action becomes final."

That instruction has a federal parent. 42 CFR 431.221(b) says the agency "may not limit or interfere with the applicant's or beneficiary's freedom to make a request for a hearing," and (c) says the agency may assist in submitting and processing it. Filing late and being told at a pre-hearing conference that it was late is a materially different outcome from not filing.

Aid continuing runs on an earlier clock, and an application denial has none

This is where the two clocks get confused, and the confusion costs money in both directions.

The federal rule is 42 CFR 431.230(a), and its heading gives the game away: Maintaining services. Where the agency sent the 10-day or 5-day notice required by 431.211 or 431.214, and the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing. Two narrow exceptions: it is determined at the hearing that the sole issue is one of federal or state law or policy, and the agency promptly informs the beneficiary in writing that services will stop pending the decision.

Three consequences follow, all of them counterintuitive.

The aid-continuing deadline is earlier than the filing deadline. In a state allowing 90 days to file, a request made on day 45 is perfectly timely and buys nothing in the meantime if the action took effect on day 12. The two dates are unrelated, and both are somewhere on the notice.

An initial application denial has no aid to continue. If a parent applied for long-term care Medicaid from a nursing home bed and the application was denied, there is nothing to maintain — the facility keeps billing privately while the hearing is pending, and a favourable decision reaches back later, in the way the last section describes. The maintaining-services rule protects an existing beneficiary facing termination, reduction or suspension. It is not a stay of a denial.

Continued benefits are recoverable. 431.230(b) provides that if the agency's action is sustained by the hearing decision, the agency "may institute recovery procedures against the applicant or beneficiary to recoup the cost of any services furnished the beneficiary, to the extent they were furnished solely by reason of this section." At nursing facility rates, several months of continued coverage that later gets reversed is not a rounding error. That does not make aid continuing a bad idea. It makes it a decision to take deliberately rather than by default.

There is a second, softer route in 42 CFR 431.231. The agency may reinstate services where a hearing is requested not more than 10 days after the date of action, and must reinstate where the action was taken without the advance notice 431.211 or 431.214 required, the beneficiary requests a hearing within 10 days of receiving the notice, and the action resulted from something other than the application of federal or state law or policy. Buried in (c)(2) is a presumption worth memorising: "the date on which the notice is received is considered to be 5 days after the date on the notice, unless the beneficiary shows that he or she did not receive the notice within the 5-day period." Five days is the assumption; later actual delivery is something you have to demonstrate.

The vocabulary changes at every state line, which is why searching for the wrong phrase turns up nothing at all.

New York calls it aid continuing. Under 18 NYCRR § 358-3.6(a)(1) the right exists where the agency was required to give timely notice and the hearing is requested before the effective date of the proposed action, and it explicitly includes the right to have a spenddown liability continue unchanged. Where assistance was already reduced or discontinued, subparagraph (ii) requires restoration "as soon as possible but no later than five business days" after the Office of Administrative Hearings notifies the district that the person was entitled to it. And subparagraph (iv) covers a calendar problem nobody thinks about until it happens: if the effective date of the proposed action falls on a weekend or holiday, a request postmarked or received on the next business day is still timely for aid continuing.

One asymmetry in the New York text is worth reading rather than assuming. Subdivision (d) of 358-3.6 is the recoupment provision — lose the hearing and the district "may recover the benefits or services which you should not have received" — and the benefits it names are the public assistance grant, child care services, and food stamps. Medical assistance is not in that list, although subdivisions (a) and (b) both name it in terms when they set out when it continues and when it does not. The federal rule at 431.230(b) permits recovery of continued services without that carve-out. Two texts, one silence: a question to put to the district in writing before electing aid continuing, not a conclusion to act on.

Texas calls it continued benefits. 1 TAC § 357.11(b)(2) tracks the federal rule nearly word for word: if a hearing is requested before the date a service is scheduled to be terminated, suspended or reduced, the agency may not take that action before a decision is rendered, subject to the same sole-issue-of-law exception. Section (b)(1)(A) also requires the written notice to contain "an explanation of the circumstances under which Medicaid is continued if a hearing is requested" — the state twin of 431.210(e).

Which denial you got decides what the hearing is about

Long-term care Medicaid produces at least four distinguishable denials, and each calls for a different argument. The heading on the letter almost never tells you which one it is. The reasons paragraph does.

Financial ineligibility. Countable resources above the standard, or income above the special income level. The 2026 federal reference points come from one page: the standards chart attached to the CMS Center for Medicaid and CHIP Services informational bulletin of 27 April 2026, read on 9 September 2026. It gives an SSI federal benefit rate of $994.00 a month and a resource standard of $2,000.00 for an individual, $1,491.00 and $3,000.00 for a couple, and it states the 300% institutional income cap outright rather than leaving it to be multiplied: $2,982.00. On the same chart, a community spouse's protected resource allowance runs from a minimum of $32,532.00 to a maximum of $162,660.00, and the home equity limit is a minimum of $752,000.00 and a maximum of $1,130,000.00 — a range because the statute lets each state pick its point within it, not because the figure is uncertain. The two SSI numbers match the Social Security Administration's own 2026 COLA fact sheet, read the same day. The full 2026 table, with the source behind each figure, is in who pays for long-term care. At a hearing, the question is almost never what the standard is. It is which items were counted, and at what value.

A transfer penalty. This one is not really an eligibility denial at all. The person may be entirely eligible; the state is refusing to pay for nursing facility services for a number of months. The look-back is 60 months for disposals made on or after 8 February 2006, under 42 U.S.C. § 1396p(c)(1)(B)(i). The penalty is arithmetic, set out at (c)(1)(E)(i): the total cumulative uncompensated value of assets transferred, divided by the average monthly cost to a private patient of nursing facility services in the state — or, at the state's option, in the community where the person is institutionalised — at the time of application. Clause (iv) forbids a shortcut in the state's favour: "a State shall not round down, or otherwise disregard any fractional period of ineligibility."

That divisor is a published number, which makes the division checkable. New York issues it to local districts every December. GIS 25 MA/14, dated 22 December 2025 and effective 1 January 2026, sets seven regional rates: New York City $15,282, Long Island $15,193, Northern Metropolitan $15,024, Northeastern $14,783, Rochester $15,675, Central $14,146, Western $13,765. The memo also tells districts which rate to use — the one in effect as of the date of application, for the region where the facility is located. Applying last year's rate, or a neighbouring region's, changes the number of months.

The start date is its own argument. Under 1396p(c)(1)(D)(ii), for transfers on or after 8 February 2006 the penalty begins on the later of the month of the transfer or "the date on which the individual is eligible for medical assistance under the State plan and would otherwise be receiving institutional level care ... but for the application of the penalty period" — and it may not run during any other period of ineligibility. A penalty that the notice starts on the date of the gift rather than on the date of institutional eligibility has started in the wrong place.

And there is a waiver that almost nobody is told about. Section 6011(d) of the Deficit Reduction Act of 2005, Pub. L. 109-171, requires every state to operate a hardship waiver process under section 1917(c)(2)(D) of the Act, under which undue hardship exists where the transfer rule would deprive the individual of medical care such that health or life would be endangered, or of food, clothing, shelter or other necessities of life. The statute then requires that process to provide three specific things: notice to recipients that an undue hardship exception exists, a timely process for determining whether the waiver will be granted, and a process under which an adverse determination can be appealed. Where a penalty notice says nothing about hardship, the silence itself is worth raising.

Two more sentences sit in the statute itself, in the text following 1396p(c)(2)(D), and they were written for precisely the situation of a parent already in a bed. The state's hardship procedures "shall permit the facility in which the institutionalized individual is residing to file an undue hardship waiver application on behalf of the individual" with the consent of the individual or their personal representative — so the applicant is not necessarily the one who has to assemble it. And while such an application is pending for a nursing facility resident, if it meets the criteria the Secretary specifies, "the State may provide for payments for nursing facility services in order to hold the bed for the individual at the facility, but not in excess of payments for 30 days." May, not must, and capped at 30 days. It is the only bed-hold provision anywhere in section 1396p, and a facility that has never used it will not mention it.

A level-of-care denial. The money is fine; the state says the person does not meet nursing facility level of care, or a PASRR determination went the other way. 42 CFR 431.220(a)(3) grants hearing rights over preadmission screening and resident review determinations specifically, and 431.241(c) puts them squarely inside what the hearing must cover. When the dispute is medical rather than financial, 431.240(b) is the paragraph to know: where the hearing involves medical issues and the hearing officer considers an independent medical assessment necessary, it "must be obtained at agency expense and made part of the record."

Approved, but nothing has started. Waiver services with a waiting list are a separate category, and sitting on a list is not the same as being denied — a distinction with its own paperwork, covered in what "approved but waiting" means.

The verification denial, and the sentence that makes it appealable

The most common long-term care denial is not about money at all. It says the applicant failed to provide requested verification — a bank statement from four years ago, a life insurance cash surrender value, a deed, an explanation of a $9,000 withdrawal.

Two regulations sit underneath it. 42 CFR 435.952(c)(2)(iii) requires the agency to give "a reasonable period to furnish any additional information." And (d) is the operative sentence: the agency "may not deny or terminate eligibility or reduce benefits for any individual on the basis of information received ... unless the agency has sought additional information from the individual in accordance with paragraph (c) of this section, and provided proper notice and hearing rights." Note the boundary in the words the ellipsis covers — the information in question is information received under the verification rules at 435.940 through 435.960, which is where data matches and document requests live. It is not a general rule about every fact an agency ever learns.

Alongside it, 42 CFR 435.916(f)(1) requires that "prior to making a determination of ineligibility, the agency must consider all bases of eligibility." A denial on one basis, where a second basis was never examined, is a denial that skipped a step.

The renewal case has one more provision, and it comes with a caveat that is easy to over-read. Under 435.916(a)(3)(iii), where a beneficiary is terminated for failing to submit the renewal form or the necessary information, the agency must reconsider eligibility in a timely manner if the form arrives within 90 days after the date of termination, or a longer period elected by the State, without requiring a new application. That trailing clause is the one to ask about first, because it is the only part of the sentence a state can make more generous. That paragraph sits in the subsection governing renewals for people whose financial eligibility is determined using MAGI-based income. Long-term care applicants are generally not in that group — they are the aged, blind and disabled population excepted from MAGI under 435.603(j) — and paragraph (b) says the agency may adopt the (a)(3) procedures for them. So the 90-day reconsideration is guaranteed to one group and optional for the other. Ask in writing whether the state has adopted it, and file the hearing request in parallel rather than waiting for an answer. The stamp costs nothing; discovering on day 95 that the reconsideration was never on the table costs the appeal.

One last denial that is not a denial: silence. 42 CFR 431.220(a)(1) grants a hearing to anyone who believes the agency "has not acted upon the claim with reasonable promptness," and 42 CFR 435.912(c)(3) — as amended at 91 FR 33480, 3 June 2026 — caps the determination at 90 days for applicants who apply on the basis of disability and 45 days for all other applicants. A parent over 65 applying on the basis of age falls in the 45-day group, not the 90-day one, which surprises people who have read about Medicaid disability timelines. Paragraph (g) adds that the agency must not use the standards "as a waiting period before determining eligibility," nor as a reason for denying eligibility because it failed to meet them. An application sitting for four months with nothing in the mail is appealable on its own terms.

Filing it: five states, five different envelopes

42 CFR 431.221(a)(1) requires states to accept hearing requests through the modalities in 435.907(a) — website, telephone, mail, in person, and other electronic means, with the internet, telephone and electronic channels phased in on the schedule in 435.1200(i). In practice, the channels that reliably work today and the addresses behind them differ.

New York. In writing, by telephone, by electronic means, by facsimile, or in person, under 18 NYCRR § 358-3.5(a). The recipient is not the local social services district that issued the denial: the regulation measures timeliness by the date a request is "postmarked or received by OAH" — the Office of Administrative Hearings — and 358-3.6 gives OAH, not the district, the job of deciding entitlement to aid continuing and telling the district what it owes. One more calendar rule sits in 358-3.5(b)(7), separate from the aid-continuing version described earlier: if the last day to request a hearing falls on a weekend or holiday, a request postmarked or received the next day counts as timely.

Texas. In writing or orally, under 1 TAC § 357.3(b)(3). HHSC's own client FAQ names the letter and the route together: instructions for requesting an appeal are printed on the Notice of Agency Action, and where no notice arrived, the fallback is 2-1-1 or the local office, with the request made "in person, by phone, fax or mail." Whichever channel is used, the agency then has to create the appeal in its TIERS Hearings and Appeals module within five calendar days of the date the hearing was requested — handbook section 1440, revision 25-3 — and that duty applies to requests made after the 90-day window too. Ask for the appeal number, and note the date you asked for it. The same FAQ adds a detail that decides whether anyone is heard at all: most Texas hearings are held by phone and you have to call in, using the toll-free number and code printed on the Notice of Hearing.

Florida. The Appeal Hearings Section takes requests four ways, per the DCF page on how to request a public assistance hearing: by mail to Appeal Hearings Section, 2415 North Monroe Street, Suite 400-I, Tallahassee, Florida 32303-4190; by email to appeal.hearings@myflfamilies.com; by phone at (850) 488-1429; or through the online form. Florida's denial letter has a name worth using on the phone — the Notice of Case Action.

California. Online, by phone to the State Hearings Division at (800) 743-8525, in writing to the county welfare department at the address shown on the Notice of Action, or by mail to the California Department of Social Services, State Hearings Division, P.O. Box 944243, Mail Station 9-17-442, Sacramento, California 94244-2430, per the department's hearing requests page. The written route has a form already in the envelope: CDSS says to complete the "Request for State Hearing" printed on the back of the Notice of Action, or to write the same information on a separate sheet — name, address, telephone number, the county that acted, the programme, and a detailed reason. It also says to keep a copy, which is advice about the only proof of filing most people will ever have.

Pennsylvania. The request goes to the agency that issued the decision, and 55 Pa. Code § 275.4(a)(2) then imposes a trap with no analogue in the other four states. An appeal "will usually be made in writing," must specify the action appealed from, and must be signed by the applicant or recipient. An oral appeal has to be reduced to a signed writing by the client within 3 working days, and if it is not, "the appeal will not be considered." A phone call to a Pennsylvania county assistance office is the start of an appeal, not an appeal.

Whatever the channel, one sentence belongs in the request in every state: an explicit ask for an expedited hearing if the circumstances warrant it. 42 CFR 431.224(a)(1) requires every state to establish and maintain an expedited process where the ordinary timeframe "could jeopardize the individual's life, health or ability to attain, maintain, or regain maximum function," and 431.242(f) makes requesting one a procedural right. The agency has to tell you whether the request is granted or denied as expeditiously as possible.

What a fair hearing is, procedurally, before anyone walks in

Most of what decides these cases happens before the hearing date, and it comes out of one paragraph almost nobody exercises.

42 CFR 431.242(a) gives the applicant or beneficiary the right to examine, "at a reasonable time before the date of the hearing and during the hearing," both the content of the case file and electronic account, and all documents and records the agency or the facility intends to use at the hearing. That means the caseworker's arithmetic, the resource worksheet, and the notes recording which document was requested on which date. Asking for it converts a hearing about what you believe happened into a hearing about what the record shows.

The rest of (b) through (e): bring witnesses, establish all pertinent facts and circumstances, present an argument without undue interference, and question or refute any testimony or evidence, "including opportunity to confront and cross-examine adverse witnesses."

42 CFR 431.240(a) requires a reasonable time, date and place, adequate written notice of the hearing, and one or more impartial officials "who have not been directly involved in the initial determination of the action in question." 431.243 adds that where the hearing involves eligibility and a different agency makes eligibility determinations, that agency must participate — so the office that actually made the call has to appear, rather than sending its paperwork ahead alone.

The decision has to be written, has to summarise the facts, and has to identify the regulations supporting it (431.244(d)); in a de novo hearing it must specify the reasons for the decision and identify the supporting evidence and regulations (431.244(e)). It must rest exclusively on evidence introduced at the hearing (431.244(a)).

Timing: 431.244(f)(1)(ii) requires final administrative action ordinarily within 90 days from the date the agency receives the request. For an expedited hearing on an eligibility claim, a nursing facility transfer or discharge, or a PASRR determination, (f)(3)(i) requires action as expeditiously as possible and — effective no later than the date described in 435.1200(i) — no later than 7 working days after the request. That cross-reference is worth following rather than trusting, because 435.1200(i) names no date. It defines one as 6 months after CMS publishes a Federal Register document telling states to comply, and records that the earliest such publication would have been 30 May 2017. The "as expeditiously as possible" half binds now. The outer 7-working-day cap is the half a state may tell you is not yet applicable to it, and the same qualifier sits on the internet, telephone and electronic filing channels in 431.221(a)(1)(i). Delay is allowed under (f)(4) only where the appellant requested it or failed to take a required action, or there was an administrative or other emergency beyond the agency's control — and the agency must document the reason in the appellant's record.

Two ways to lose without a hearing, both in 431.223: withdrawing the request, or failing to appear at a scheduled hearing without good cause. And one issue the agency "need not grant a hearing" on, under 431.220(b): where the sole issue is a federal or state law requiring an automatic change adversely affecting some or all beneficiaries. Texas writes the same exception into its own rule at 1 TAC § 357.3(b)(4)(B) and adds where it gets decided — "this may be determined at a preliminary hearings conference" — alongside (b)(4)(C), which preserves the right to argue that you are not in the affected class at all. Arguing that a standard is too low is not a hearing issue. Arguing that the standard was applied wrongly to this person is.

Not the notice with the noon deadline, and not the one from the facility

Three different pieces of paper can arrive in the same month, and they run on completely different rules. Confusing them is the most common way a family misses a deadline it never knew existed.

The Medicare fast appeal is a different world with a different reviewer and a deadline measured in hours — the NOMNC deadline is noon of the next calendar day rather than a number of days, and the reviewer is a federal contractor, not the state agency. If the dispute is whether skilled care remains medically necessary because a parent has stopped improving, that argument belongs to the Jimmo settlement and maintenance coverage, not to a Medicaid fair hearing. And if the letter came from the facility rather than from an agency, start with what to read first in an involuntary discharge notice — noting that 42 CFR 431.220(a)(2) does give the resident a state fair hearing right over a facility's transfer or discharge decision, which is exactly why the state agency's hearing information has to be provided at the time the facility delivers its notice.

If the decision goes your way, the money runs backwards

This is the part that makes the whole exercise worth the postage, and it is one short regulation.

42 CFR 431.246 requires the agency to "promptly make corrective payments, retroactive to the date an incorrect action was taken," and, if appropriate, to provide for admission or readmission of an individual to a facility — where the hearing decision is favourable to the applicant or beneficiary, or where the agency decides in their favour before the hearing.

Both halves matter. Retroactivity is why an application denial with no aid continuing is still worth appealing: the private-pay months that pass during the appeal are not simply gone if the denial is reversed. And the second trigger is why a well-documented request sometimes never reaches a hearing room — agencies do reverse themselves once someone points at the resource worksheet, and the corrective payment obligation is identical either way.

42 CFR 431.245 requires written notice of the decision and of the right to request a state agency hearing or seek judicial review, to the extent either is available. In states that run local evidentiary hearings first, 431.232 gives 10 days from receipt of an adverse local decision to appeal it to the state agency — with the same five-day receipt presumption — plus the right to ask that the state-level appeal be a de novo hearing.

The counterweight stays where it was. If services were continued under 431.230 and the agency prevails, 431.230(b) lets the state pursue the cost of what was furnished solely because of that continuation. A favourable decision reaches backwards. So does an unfavourable one.

Two offices are worth calling before the deadline, and neither of them is the facility's business office: the state's legal aid or elder law programme, and the long-term care ombudsman for the state, whose number the facility is required to post. Neither charges anything. Both have read more of these notices than anyone in the building.

Sources

Federal regulations were read on 9 September 2026 through the eCFR versioner API for title 42, against the text issued 13 August 2026, which eCFR reports as current through 4 September 2026. State rules and the two federal standards documents were read the same day. Both ssa.gov and medicaid.gov refuse automated requests, so those two pages were retrieved through a rendering proxy and the Social Security figures were confirmed a second time in a browser; the links below are the publishers' own addresses and open normally.

• 42 CFR part 431, subpart E — § 431.206 informing applicants and beneficiaries; § 431.210 content of notice; § 431.211 advance notice; § 431.213 exceptions from advance notice; § 431.214 notice in cases of probable fraud; § 431.220 when a hearing is required; § 431.221 request for hearing; § 431.223 denial or dismissal of a request; § 431.224 expedited appeals; § 431.230 maintaining services; § 431.231 reinstating services; § 431.232 adverse decision of a local evidentiary hearing; § 431.240 conducting the hearing; § 431.241 matters to be considered; § 431.242 procedural rights; § 431.243 parties in eligibility cases; § 431.244 hearing decisions; § 431.245 notifying of the decision; § 431.246 corrective action.
• 42 CFR part 435, subpart J — § 435.912 timely determination of eligibility, as amended at 91 FR 33480 (3 June 2026); § 435.916 periodic renewal; § 435.917 notice of the agency's decision; § 435.952 use of information and requests for additional information; § 435.1200(i) notice of applicability date, which governs when the 7-working-day expedited cap and the electronic filing channels become binding.
• 42 U.S.C. § 1396p(c) — look-back date, penalty start date, penalty calculation, and the bar on rounding down. Hardship waiver requirements: Deficit Reduction Act of 2005, Pub. L. 109-171, § 6011(d), reproduced in the notes to that section. The facility's right to file a hardship application on the resident's behalf and the 30-day bed-hold option are in the undesignated text following § 1396p(c)(2)(D).
• New York: 18 NYCRR § 358-3.5 requests for a fair hearing; § 358-3.6 aid continuing. New York State Department of Health, GIS 25 MA/14, Medicaid Regional Rates for Calculating Transfer Penalty Periods for 2026, issued 22 December 2025, effective 1 January 2026.
• Texas: 1 TAC § 357.3 authority and right to appeal; 1 TAC § 357.11 notice and continued benefits. Texas Health and Human Services, Fair and Fraud Hearings Handbook § 1400 — §§ 1410, 1420 and 1440 at revision 25-3, effective 15 May 2025, and § 1430 at revision 23-1, effective 31 July 2023. HHSC Fair and Fraud Hearings Handbook client FAQ — the Notice of Agency Action, the 2-1-1 and local office route, and the call-in format of most hearings.
• Florida: Fla. Admin. Code R. 65-2.046, time limits in which to request a hearing, amended effective 2 April 2018. Florida Department of Children and Families, Appeal Hearings, which names the Notice of Case Action as the letter the 90 days runs from, and How to Request a Public Assistance Hearing for the address, email and telephone number.
• California: Welfare and Institutions Code § 10951. California Department of Social Services, Hearing Requests.
• Pennsylvania: 55 Pa. Code § 275.3 requirements and time limitations; § 275.4 procedures. The Pennsylvania Code site states that it reflects changes effective through 56 Pa.B. 4026, 4 July 2026.
• 2026 standards: CMS Center for Medicaid and CHIP Services informational bulletin Updated 2026 SSI and Spousal Impoverishment Standards, 27 April 2026, and the 2026 standards chart attached to it — source of the FBR, resource standard, 300% income cap, community spouse resource minimum and maximum, and home equity minimum and maximum quoted above. Social Security Administration, 2026 cost-of-living adjustment fact sheet — SSI federal payment standard of $994 for an individual and $1,491 for a couple and resource limits of $2,000 and $3,000, after a 2.8% COLA.

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