Medi-Cal appeals and estate recovery run on two separate tracks with strict deadlines. If Medi-Cal denies, reduces, or terminates your eligibility or a service, you have 90 days from the Notice of Action to request a state fair hearing (120 days if the denial came from a managed care plan). If the state files an estate recovery claim after a beneficiary dies, heirs have 60 days from the claim letter to apply for a hardship waiver, and can also dispute the claim itself through a hearing.
Start With the Notice of Action
Every Medi-Cal dispute begins with a written Notice of Action (NOA). When a county, the Department of Health Care Services (DHCS), or a managed care plan denies, reduces, or ends your eligibility or services, it must send you a notice describing the action, the effective date, the legal basis, and your right to a state hearing.1New York Codes, Rules and Regulations. 22 CA ADC 50179 – Notice of Action – Medi-Cal-Only Determinations or Redeterminations Every deadline in your appeal runs from the date on that notice. Keep it.
The 90-Day Deadline to Request a State Fair Hearing
You have 90 days from the date the NOA was mailed or handed to you to request a state fair hearing.2California Department of Health Care Services. State Fair Hearing Request Form Miss it and an Administrative Law Judge may still accept a late request filed within 180 days if you show good cause. After 180 days, the door closes.
File using the State Fair Hearing Request Form that came with your NOA, or by phone, fax, email, or mail to the California Department of Social Services State Hearings Division.3California Department of Social Services. Hearing Requests Include your name, Medi-Cal ID number, address, phone number, and a plain explanation of why you think the action was wrong. Attach anything that helps: medical records, letters from treating physicians, income documents, correspondence with the county.
You do not need a lawyer. Federal law lets you represent yourself or bring counsel, a relative, a friend, or anyone else to speak for you.4eCFR. Subpart E – Fair Hearings for Applicants and Beneficiaries You can also request a free interpreter, including sign language.
Managed Care Plans: Appeal Internally First
If your Medi-Cal comes through a managed care plan and the plan denies or limits a service, you generally have to finish the plan’s internal grievance and appeal process before the state will hear you. Only after the plan issues its final decision, called a Notice of Appeal Resolution (NAR), can you go to a state hearing. There is one shortcut: if the plan misses its required notice or timing rules, the internal process is treated as exhausted and you can go straight to the state.
Once the NAR arrives, you have 120 days to request a state fair hearing. The clock runs from the date on the NAR, not the original service denial.
Keeping Benefits Running: Aid Paid Pending
If Medi-Cal is cutting or ending services you already receive, you can request “aid paid pending” to keep them going while the appeal is decided. It only covers services you already have, not new services you asked for and were denied.2California Department of Health Care Services. State Fair Hearing Request Form
The window is short. Your hearing request has to be received or postmarked within 10 calendar days of the NOA date, or before the date the notice says services will end, whichever is later. Miss it and services stop while the appeal moves forward.
One caution: if you keep services under aid paid pending and then lose the hearing, the agency can seek to recover the cost of those services. For most people, keeping care in place is the more pressing concern, but if the dollar amounts are significant, talk to a legal representative before filing.
What Happens at the Hearing
The hearing is before an Administrative Law Judge at the State Hearings Division, which sits within the California Department of Social Services.5California Department of Social Services. State Hearings It is less formal than a courtroom trial, but the outcome is binding.
Who has to prove what depends on the action. When the agency is trying to terminate or reduce benefits you already have, it usually carries the burden of showing the change was justified. When you are seeking new eligibility or a service you have never received, the burden is on you. You have the right to review the agency’s case file before the hearing, present your own testimony and documents, and question the agency’s witnesses.
Decision Deadlines
Federal law requires a final administrative decision within 90 days of your hearing request.6eCFR. 42 CFR 431.244 – Hearing Decisions For managed care appeals that qualify for expedited resolution, the decision must issue within three working days after the state receives the case file. You qualify for expedited review if the standard timeline could put your life or health at risk, or jeopardize your ability to maintain or regain basic functioning.7eCFR. 42 CFR 431.224 – Expedited Appeals
The ALJ issues a proposed decision; the Director of the relevant department then adopts, modifies, or rejects it. The adopted version is the final administrative decision.
If You Lose: Superior Court Review
After an unfavorable final decision, the next step is a Petition for Writ of Administrative Mandamus in Superior Court under California Code of Civil Procedure section 1094.5. You have one year from the date you received notice of the final decision to file it.8California Legislative Information. California Welfare and Institutions Code 10962
Two features make this more accessible than typical civil litigation. There is no filing fee, and if you win, the court must award reasonable attorney’s fees and costs.8California Legislative Information. California Welfare and Institutions Code 10962
The court does not hold a new trial or take new evidence. Its review is limited to the administrative record. The judge examines whether the agency stayed within its jurisdiction, whether you got a fair hearing, and whether the factual findings are supported by substantial evidence, meaning evidence a reasonable person would accept as enough to support the conclusion. If the decision fails that test, the court issues a writ ordering the agency to set it aside and reconsider.
Estate Recovery After a Beneficiary Dies
The second track opens after a Medi-Cal beneficiary dies. The state can seek to recover costs it paid on the beneficiary’s behalf, but SB 833, effective January 1, 2017, sharply narrowed what it can go after.9California Department of Health Care Services. Estate Recovery Program For beneficiaries who died on or after that date, recovery is limited to payments for nursing facility services, home and community-based services, and related hospital and prescription drug services. Routine medical care received after age 55 is no longer recoverable.
Recovery reaches only the deceased beneficiary’s probate estate, meaning property they owned individually at death.10California Legislative Information. California Welfare and Institutions Code 14009.5 Assets in a living trust, joint tenancy property that passed to a surviving co-owner, and other property that transferred outside probate are generally out of reach. That gap is why many Medi-Cal beneficiaries do estate planning while alive.
Who Blocks Estate Recovery Entirely
DHCS cannot pursue any recovery claim if the beneficiary is survived by:
- A spouse or registered domestic partner. The claim is deferred entirely and cannot be revived during the survivor’s lifetime.
- A child under 21.
- A child of any age who is blind or has a permanent disability.
These bars are absolute. If a qualifying survivor exists at the time of death, DHCS cannot file a claim against the estate regardless of its value.10California Legislative Information. California Welfare and Institutions Code 14009.5
Fighting an Estate Recovery Claim
Heirs who receive a claim letter from DHCS can request a hearing to dispute the amount or validity. Common arguments: the property was not part of the probate estate, the amount exceeds what the law allows under the post-2017 limits, or a qualifying survivor exists whom DHCS did not account for.
The 60-Day Hardship Waiver
Even a valid claim can be waived for substantial hardship. The application has to be submitted within 60 days of the date on the DHCS claim letter.11California Department of Health Care Services. Hardship Waiver Application Grounds include losing a primary residence to the claim, or having provided care that kept the beneficiary out of a nursing facility. For beneficiaries who died on or after January 1, 2017, additional criteria apply, including a provision for homesteads of modest value.
Federal law also requires the state to waive recovery when it would cause undue hardship, and it cannot deprive a person of food, clothing, shelter, or other basic necessities.12Office of the Law Revision Counsel. 42 U.S. Code 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets If DHCS denies a hardship waiver, that denial can itself be appealed through the same state fair hearing process.