How to Appeal a Medicaid Denial in Texas: Deadlines and Hearings

To appeal a Medicaid denial in Texas, start with the notice you received: if a managed care plan denied, reduced, or terminated a service, file an internal appeal with the plan within 60 days, and then request a state fair hearing if the plan upholds the denial. If the Texas Health and Human Services Commission (HHSC) denied your eligibility, you can go straight to a state fair hearing. Deadlines drive the whole process, and the shortest one — 13 days to keep your existing benefits running while you appeal — comes up first.

Start With Your Denial Notice

Your denial notice tells you why you were denied, who denied you, and how long you have to act.¹ Those three facts decide your next move.

Denials generally fall into a few categories: household income above the program limit, missing documents or verification, failure to meet a categorical requirement like age, disability, or pregnancy status, or a finding that a requested medical service isn’t medically necessary. An income denial is a documents problem. A medical necessity denial is a doctor’s-letter problem. Pinning down which one you have tells you what to gather.

The notice also identifies the sender. A notice from HHSC is an eligibility action. A notice from a managed care organization (MCO) is a service action, and it goes through a different track first.

If an MCO Denied a Service: Internal Appeal First

Most Texas Medicaid recipients get care through an MCO. Federal rules require you to finish the MCO’s internal appeal before you can request a state fair hearing on a service denial.² Skipping this step is a common reason state hearing requests get rejected.

You have 60 days from the date on the MCO’s adverse benefit determination notice to file an internal appeal.³ You can usually file by phone, fax, or in writing. The MCO then has up to 30 calendar days to resolve the appeal and notify you.⁴

If the MCO upholds the denial, or fails to answer in time, you’ve exhausted the internal process.² The written decision will include a form for requesting a state fair hearing.⁵

Requesting a State Fair Hearing

A state fair hearing puts your case in front of an impartial hearing officer. How you get there depends on the type of denial:

Eligibility denials from HHSC: 90 calendar days from the effective date of the action or the date on the notice, whichever is later.⁶
Service denials from an MCO (after the internal appeal): 120 days to request the state fair hearing.⁷

Your request can be oral or written.⁸ Three ways to file it:

Call 2-1-1, the state’s health and human services helpline.
Mail or fax a written request that includes your name, address, Medicaid case number, and why you disagree with the decision.
File in person at any HHSC office.⁷

Even if you call first, follow up in writing. A written request creates a paper trail if there’s ever a dispute about filing on time. If your request arrives after the deadline, only the hearing officer can accept it, and only for good cause.⁶

The 13-Day Window to Keep Benefits

If you’re already receiving Medicaid and HHSC sends a notice reducing or terminating your benefits, you can keep them running during the appeal. The catch is the deadline: you must request a fair hearing within 13 days of the adverse action notice.⁹ A mailed request postmarked within that window counts.

You still have the full 90 days (or 120 for MCO actions) to file your appeal itself. The 13 days is only about uninterrupted coverage while you wait. Miss it and your benefits stop even though the appeal goes forward.

One risk to weigh: if the hearing officer sides with the agency, HHSC can file a claim to recover the cost of benefits paid during the appeal period.⁹ Recoupment is uncommon in practice, but it’s a possibility worth considering, particularly on a reduction rather than a full termination.

Expedited Hearings for Urgent Medical Situations

If waiting for a standard hearing could jeopardize your life, physical health, mental health, or ability to function, you or your doctor can request an expedited hearing.¹⁰ For Texas Medicaid, the hearing must be held and a decision issued within five working days of the hearing officer receiving the request.¹¹

A doctor’s statement explaining the medical urgency strengthens the request. Call 2-1-1 rather than mailing anything.

Preparing for the Hearing

A hearing officer decides based on what you and the HHSC representative present. There’s no independent investigation. If you don’t bring the evidence, it isn’t in the record.

Gather the Right Evidence

What you need depends on why you were denied. For income denials, collect pay stubs, tax returns, bank statements, and documentation of allowable deductions. For medical necessity denials, get a detailed letter from your treating doctor explaining why the service is needed and what happens without it. In every case, keep copies of all correspondence with HHSC and your MCO.

Review Your Case File Before the Hearing

Federal law gives you the right to examine your complete case file and every document the agency plans to use, at a reasonable time before the hearing.¹² For MCO-related appeals, the plan must send you this information within 10 calendar days of your hearing request.⁵ Use this right. Seeing the agency’s evidence in advance lets you prepare specific responses instead of reacting on the spot.

Get Legal Help if You Can

Your denial notice includes information about free legal representation.¹ Texas legal aid organizations handle Medicaid appeals at no cost for eligible individuals. If you can’t find free representation, you can bring a friend, family member, or advocate to help you present your case. If you need an interpreter or a disability accommodation, request it when you file the hearing request so it’s arranged in time.¹²

What the Hearing Looks Like

The hearing is conducted by an impartial hearing officer from the HHSC Appeals Division. Most hearings are held by phone. Both sides present their case. You’ll explain your situation, introduce documents, and can bring witnesses such as your treating physician or a family member. The HHSC representative presents the agency’s position. The hearing officer may ask questions, and you can question the agency’s representative and challenge its evidence.

If you’re bringing a witness, prepare them. A doctor who explains the specific medical consequences of going without treatment is more persuasive than one who says the patient needs the service. Written statements make useful backup, but live testimony carries more weight.

The Decision and What Comes After

The hearing officer issues a written decision. For standard hearings, it must be mailed within 90 calendar days of the date you requested the hearing.⁵ The decision either overturns the denial, upholds it, or sends the case back for further review.

If the hearing officer sides with you, the agency must implement the decision. If not, you have two further options:

Administrative review, in which an HHSC attorney reviews the hearing officer’s decision for legal errors.
Judicial review in a Texas district court, once you’ve exhausted all administrative remedies. The petition must be filed within 30 days of the date the final administrative decision becomes appealable.¹³¹⁴

The 30-day judicial review deadline is firm. Once it passes, the administrative decision is final.

Missed a Deadline? Good Cause

Missing a filing window isn’t automatically the end. Only the hearing officer can accept a late appeal, and only if you show good cause.⁸ Circumstances that may qualify include a serious illness that prevented you from acting, a death in your immediate family, destruction of records in a disaster, receiving incorrect information about how to appeal, or never receiving the denial notice.

Good cause is a safety net, not a strategy. The further past the deadline you are, the harder it becomes to justify. Filing immediately after a denial, even before you’ve gathered evidence, preserves your rights while you prepare.

Key Deadlines at a Glance

MCO internal appeal: 60 days from the adverse benefit determination notice.
State fair hearing, HHSC eligibility denials: 90 days from the effective date or notice date, whichever is later.
State fair hearing, MCO service denials: 120 days from the MCO action.
Continuation of benefits during appeal: 13 days from the adverse action notice.
Expedited hearing decision: 5 working days after the hearing officer receives the request.
Standard hearing decision: 90 calendar days after the hearing request.
Judicial review petition: 30 days after the final administrative decision.

For questions about your case, contact the HHSC Office of the Ombudsman at 877-787-8999.¹⁵

1
Cornell Law Institute. 1 Texas Admin Code 366.421 – Right to Appeal
2
eCFR. 42 CFR Part 438 Subpart F – Grievance and Appeal System
3
Texas Health and Human Services. Medicaid Managed Care Denial and Appeals Process Study
4
eCFR. 42 CFR 438.408 – Resolution and Notification: Grievances and Appeals
5
Texas Health and Human Services. MCO Adverse Actions and the Appeals Process
6
Texas Health and Human Services. 1400, Submitting a Fair Hearing Request Summary
7
Texas Health and Human Services. Fair and Fraud Hearings
8
Texas Health and Human Services. B-1020, Time Period for Requesting Fair Hearing
9
Texas Health and Human Services. B-1050, Handling of Benefits During the Appeal Process
10
eCFR. 42 CFR 431.224 – Expedited Appeals
11
Texas Health and Human Services. 1500, Scheduling the Hearing
12
eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries
13
State of Texas. Texas Government Code 2001.171 – Judicial Review
14
State of Texas. Texas Government Code 2001.176 – Petition Initiating Judicial Review
15
Texas Health and Human Services. Contact