To challenge a denial, reduction, or termination of your Medicaid coverage in Indiana, you file the Administrative Appeal and Hearing Request form with the state’s Family and Social Services Administration. The Indiana Medicaid appeal form is free, available through the Division of Family Resources, and must be submitted in writing within 33 calendar days of your notice of action. Filing even sooner — before the effective date printed on that notice — is what keeps your benefits in place while the appeal is decided.
Where to Get the Form
FSSA publishes a printable Administrative Appeal and Hearing Request form on the Division of Family Resources website. You can also pick up a paper copy at any local DFR office. The Office of Administrative Law Proceedings (OALP), which handles FSSA appeals, keeps a resources page with submission instructions at in.gov/oalp/resources-for-fssa-appeals/.
You are not strictly required to use the form. The regulation requires a written request but does not mandate a particular format, so a letter containing the same information will be accepted. Using the official form is simpler because it prompts you for everything the agency needs.
What to Put on the Form
Before you start writing, pull out the notice of action you received in the mail. That notice contains most of what the form asks for: your case number, the date of the notice, the effective date of the action, and the specific program affected (Healthy Indiana Plan, Hoosier Care Connect, or traditional Medicaid). Copy the case number exactly as printed. A single transposed digit can delay processing.
The form asks for your full legal name, current mailing address, phone number, and the case number. It also asks you to identify the action you are appealing and why. This is the field that matters most. Skip vague phrases like “I disagree” and describe the factual reason the decision is wrong:
- If the state says your income exceeds the limit, state what your current income actually is and the approximate date it changed.
- If the notice lists the wrong household size, state the correct number of people in your home.
- If a medical service was denied, state why your doctor says it is needed.
- If a prior authorization was refused, reference the original request and the denial.
Concrete facts give the Administrative Law Judge something to work with when the file reaches them.
Naming a Representative
If someone will represent you at the hearing — a lawyer, legal aid attorney, family member, or friend — include that person’s name, address, and phone number on the form. Designating a representative authorizes FSSA to communicate directly with that person about your case. You do not need a lawyer to file or attend the hearing, but one can help if the issues are complicated.
Continued Benefits Election
The form includes a place to indicate whether you want your current benefits to continue during the appeal. Marking yes preserves your coverage; marking no (or leaving it blank in a way the agency reads as declining) stops the benefits while the appeal plays out. Read the next two sections before deciding, because this choice has real consequences in both directions.
The 33-Day Filing Deadline
Indiana law gives you 33 calendar days to file your appeal. The clock starts from the effective date of the action or the date printed on the notice of action, whichever is later. The appeal must be received by close of business (4:30 p.m. local time) on or before the 33rd day. If that day falls on a weekend, state holiday, or a day the receiving office is closed, the deadline extends to the next business day. An appeal received after close of business on the 33rd day is considered untimely.1Legal Information Institute. Indiana Code 405 IAC 1.1-1-3 – Filing an Appeal; Scheduling Appeals
The window is strict, with very little room for exceptions. Do not wait until the last few days to mail the form. If it arrives a day late, the appeal will likely be dismissed regardless of how strong your case is. If you are close to the deadline, fax the form and follow up with a mailed copy.
The Earlier Deadline That Protects Your Benefits
Filing within 33 days preserves your right to a hearing. Filing before the effective date of the adverse action is what preserves your coverage in the meantime. The effective date is printed on your notice of action and is usually a specific future date. If OALP receives your appeal by close of business on the day before that effective date, your Medicaid coverage continues unchanged until the judge issues a decision.2Indiana Family and Social Services Administration. Indiana Health Coverage Program Policy Manual Chapter 4200 Appeals and Fair Hearings File after the effective date but still within 33 days and your hearing right survives, but your benefits may stop or be reduced while you wait. The practical takeaway: file as soon as you get the notice.
How to Submit the Form
Send your completed appeal to the Office of Administrative Law Proceedings:3IN.gov. OALP Resources for FSSA Appeals
- Mail: Office of Administrative Law Proceedings – FSSA Hearings, 100 N. Senate Avenue, Suite N802, Indianapolis, IN 46204
- Fax: 317-232-4412
If you mail the form, use certified mail with a return receipt. That receipt is your proof the appeal was submitted before the deadline. Without it, a lost envelope means a lost appeal. If you fax the form, keep the transmission confirmation page showing the date, time, and receiving number. Make copies of everything you submit before sending it.
You can also file at a local DFR office in person. The regulation allows appeals to be filed with the Division of Family Resources or OALP.1Legal Information Institute. Indiana Code 405 IAC 1.1-1-3 – Filing an Appeal; Scheduling Appeals Walking the form into a DFR office and asking for a date-stamped copy is the most reliable way to prove timely filing when you are near the deadline.
Keeping Your Benefits During the Appeal
When you file before the effective date of the adverse action, your Medicaid benefits continue at their current level throughout the appeal. FSSA cannot reduce or terminate your coverage for the reason under appeal until the Administrative Law Judge issues a final decision. If a separate eligibility issue surfaces during the appeal period, the agency must still keep your coverage active until the hearing decision is released.2Indiana Family and Social Services Administration. Indiana Health Coverage Program Policy Manual Chapter 4200 Appeals and Fair Hearings
Two exceptions apply. Benefits do not continue if you specifically decline continued benefits on your appeal form, or if the reason for the termination was failure to pay a required Medicaid premium or a POWER account payment under the Healthy Indiana Plan.2Indiana Family and Social Services Administration. Indiana Health Coverage Program Policy Manual Chapter 4200 Appeals and Fair Hearings
Continued benefits carry a financial risk. If the judge upholds the state’s original decision, FSSA will pursue repayment of the benefits you received during the appeal period.2Indiana Family and Social Services Administration. Indiana Health Coverage Program Policy Manual Chapter 4200 Appeals and Fair Hearings For many people, keeping coverage through a months-long appeal is worth the risk, but go in knowing about it.
What Happens After You File
Once OALP logs your appeal, you will receive a hearing notice in the mail with the date, time, and instructions for attending. Hearings are conducted by phone or in person; you may need to specifically request an in-person hearing if you prefer one. The notice includes the phone number and access code for telephone hearings.
You have the right to review your entire case file before the hearing, including all documents and records FSSA used to make the decision.4Medicaid.gov. Understanding Medicaid Fair Hearings Contact your local DFR office or managed care plan to request your file a reasonable time before the hearing date. Reviewing it tells you exactly what evidence the state is relying on so you can prepare a response to each point.
Gather documents that directly contradict the state’s reasoning. Recent pay stubs or a termination letter help with income disputes. Lease agreements, school enrollment records, or birth certificates help with household-size errors. A letter from your doctor and relevant medical records help with medical necessity denials. Copies of the original authorization request and any denial letters help with prior authorization issues. Organize the documents in the order you plan to discuss them.
Failing to appear at the hearing typically results in dismissal of the appeal. If something prevents you from attending, contact OALP as early as possible to request a continuance.
If the Hearing Decision Goes Against You
An unfavorable ALJ decision is not the end of the process. Under Indiana’s Administrative Orders and Procedures Act, you can petition for judicial review in an Indiana Circuit or Superior Court. The petition must be filed within 30 days after the final agency order is served on you.5Indiana General Assembly. Indiana Code 4-21.5-5-2 – Petition; Persons Entitled to Judicial Review Miss that 30-day window and you lose access to court review entirely. The court reviews the existing administrative record and rarely accepts new evidence, which is why building a complete record at the ALJ hearing is important. Indiana Legal Services (indianalegalservices.org) provides free assistance to eligible individuals in Medicaid cases.