Medicaid Fair Hearing

Fact Sheet

What is a Fair Hearing?

If you think the South Carolina Department of Health and Human Services (DHHS) has made a wrong decision about your eligibility for Medicaid benefits or level of  benefits, you can ask for a Fair Hearing. A Fair Hearing may be your only chance to explain your side of the case. At the hearing, DHHS will explain why the Medicaid service was denied, reduced, delayed, or stopped. A DHHS hearing officer will act like a judge and listen to both sides of the case. The hearing officer will make a decision and mail it to you in writing after the hearing. The decision is based on the legal merits of the case, so it is important that you talk with a lawyer before the hearing. If possible, bring a lawyer with you to the hearing. Fair Hearings are held at the DHHS office in Columbia, unless the hearing officer decides there is a good reason to have it at a different location. All hearings that involve an adult not meeting the disability criteria will be held in the DHHS Community Long Term Care office1 that is closest to where that person

How do I know that DHHS is denying, reducing, delaying, or stopping my benefits?

DHHS must send you a letter, called a “notice,” before DHHS takes any “action” against you.2 An action means DHHS denied, reduced, delayed, or stopped your benefits.3 DHHS must mail you the letter at least 10 days before the “action” date.4

The letter you get from DHHS should tell you:

If you were told your services are going to change, but you did not get a written notice, you should immediately ask for a letter explaining the changes from your case manager, if you have one. If you do not have a case manager, call DHHS at 1-888-549-0820.

When should I ask for a Fair Hearing?

You can ask for a Fair Hearing if your Medicaid benefits have been reduced, delayed, or stopped.5 You can also ask for a Fair Hearing if your application for benefits has been
denied or if you are found eligible but are not getting benefits within a reasonable time.6 A reasonable time generally means your benefits will start within 90 days from the date DHHS found you were eligible. If you are a nursing home resident and you believe you are being wrongly discharged or transferred, you can ask for a Fair Hearing.7

How do I ask for a Fair Hearing?

You must ask for your Fair Hearing by sending a letter to DHHS within 30 days after getting your letter from DHHS that said your benefits would be stopped, reduced, or delayed, or denying your application for benefits.8 A sample letter is attached to this Fact Sheet. If you want to keep your benefits while you wait for a hearing, you may have to send your letter sooner (see the section below titled “How do I keep my benefits while I wait for a hearing?”). Send the letter asking for a Fair Hearing with a copy of the DHHS notice letter by certified mail to prove you sent it on time. Keep a copy of the letter you sent and the DHHS notice letter for your records.

What if I am in a Managed Care Plan?

If your services are provided through a Managed Care Organization (MCO), you must follow the procedures within the MCO’s own appeal process before filing a request for a
Fair Hearing. First, check with your MCO about what you need to do to file an appeal with the MCO. If you have followed all of the steps the MCO requires and are still not satisfied with the outcome, then you can file a request for a Fair Hearing.

What should I include in my letter asking for a Fair Hearing?

Where do I send my letter and a copy of the DHHS letter?

Division of Appeals and Hearings
Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206

How can I keep my benefits while I wait for the Fair Hearing?

If you want to keep your benefits, you must ask for your benefits to continue in your letter. Your benefits will be kept at the same level until the hearing officer makes a decision. The time when you must send this letter depends on what kind of notice DHHS gave you, and you may have less time than the 30 days you otherwise have to request a Fair Hearing.

What happens if the hearing is scheduled on a date I cannot attend?

Call the hearing officer and ask to change the date. Follow up with a letter if you can, so you have a record of the request. It is important that you attend the hearing as scheduled. If you do not go to the hearing on the date scheduled, the hearing officer can dismiss your case.13

How should I prepare for the Fair Hearing?

What are my rights at the Fair Hearing?

Before the hearing, you have the right to see the contents of your case file and any materials DHHS plans to use at the hearing.14 If you did not get your case file, call your caseworker or DHHS at 1-888-549-0820 and ask for a copy. If you have asked for your case file and still have not seen it at least a week before the hearing, call the hearing  officer and ask for the hearing to be postponed until you have been given the file and time to review it. Also send a letter to the hearing officer so you have a record of the request

At the hearing, you have the right to:

It is important that you present all evidence and arguments that you want the hearing officer to consider. The Fair Hearing will probably be the only chance you have to present all this information. The hearing officer can make the decision based ONLY on what is said and presented at the hearing.21 The decision is a legal determination. The
hearing officer’s duty is to decide whether a person is eligible for benefits or qualifies for a certain level of benefits under the law.

What will the Fair Hearing decision look like?

The hearing officer must send you the decision in writing. You should get this decision within 90 days from the day you asked for a Fair Hearing. The decision should list the facts presented at the hearing and explain what rules or regulations the hearing officer used making the decision.22

What if I lose the Fair Hearing or don’t agree with the decision?

DHHS can stop or reduce your services if the decision is not in your favor.23 If you had services while you waited for a hearing, you may have to pay DHHS for those services if the agency seeks repayment.24 You can still file a new application for Medicaid services, but you need to have different evidence. If you do not agree with the hearing officer’s decision, you can file an appeal to the Administrative Law Court (ALC). You must file this appeal within 30 days of the date you were notified of the decision. There is a $25 fee to appeal. If you cannot afford the fee, you can file a “Request to Waive Filing Fee” stating that you cannot afford to pay for the appeal. That form can be found at If you are appealing a DHHS hearing officer’s decision in which a hearing was held, you will be responsible for the cost of making a transcript of the hearing. A transcript is a written record of the hearing. The cost of the transcript is approximately $16 for each hour that the  transcriptionist spends typing the transcript. The rules for appealing to the ALC are found at If you do not follow the rules, your appeal may be dismissed.

Where can I find information about the rules that apply to Fair Hearings?

DHHS has regulations about Fair Hearings at 10 S.C. Code of Regulations, R. 126-150 to 126-158 found at The United
States Department of Health and Human Services, which is responsible for Medicaid, has rules about Fair Hearings starting at 42 C.F.R. § 431.200, found at The Centers for Medicare and Medicaid has a manual found at (click on
“Paper-Based Manuals”). The manual is called “The State Medicaid Manual” in Chapter 2, “State Organization.” If you do not have access to the internet, your public library may be able to help you get the information. If you have trouble finding the right laws or rules that apply, contact P&A for help locating them.

How do you contact P&A?

For information or assistance, please contact P&A at any of the following: /
Fax 803-790-1946
Toll free in SC: 1-866-275-7273 (VOICE) and 1-866-232-4525 (TTY)

Sample Letter Requesting a Medicaid Fair Hearing

Date: ____________________________

Division of Appeals and Hearings
Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206

Re: Fair Hearing Request for: _____________________________________________________ (name)

Dear Sir or Madam:

I am writing to request a Fair Hearing regarding the decision of ________________________________ ______________________ (agency) on _____________________ (date) to do the following:

A copy of the letter taking such action is enclosed. Please continue (my, my child’s) services at the present amount pending this Fair Hearing.

I believe this decision was incorrect for the following reasons:

Please send a complete copy of the case file for __________________________________________ (name) and copies of any materials you plan to use at the Fair Hearing pursuant to 42 U.S.C. § 431.242.

I have the following special request(s):

________________________________ (printed name)

Enclosure: Copy of DHHS notice of ______________(date)

cc: Anna Maria Darwin, Protection and Independence Team Leader,
Protection and Advocacy for People with Disabilities, Inc.
545 N. Pleasantburg Drive, Suite 106
Greenville, SC 29607


1 For locations, contact DHHS at 803-898-2590 or see Community Long Term Care section of the DHHS website:
2 42 C.F.R. § 431.210. This is the section of the Code of Federal Regulations (“C.F.R.”), where you can find the rules that apply to Medicaid agencies. The South Carolina Code of Regulations (“S.C. Code Ann.
Regs.”) also apply to the South Carolina Medicaid agency, DHHS. There is a section at the end of this fact sheet that explains where to find those rules.
3 42 C.F.R. § 431.201.
4 42 C.F.R § 431.211.
5 42 C.F.R. § 431.200(b).
6 42 C.F.R. § 431.200(a).
7 42 C.F.R. § 431.200(c).
8 42 C.F.R. § 431.221; 10 S.C. Code Ann. Regs. 126-152 (2012)
9 42 C.F.R. § 431.230.
10 42 C.F.R. § 431.231(c).
11 42 C.F.R. § 431.231(a).
12 42 C.F.R. § 431.230(b).
13 42 C.F.R. § 431.223.
14 42 C.F.R. §§ 431.242(a) (1) & (2).
15 10 S.C. Code Ann. Regs. 126-158 (2012)
16 42 C.F.R. § 431.242(d); 10 S.C. Code Ann. Regs. 126-158 (2012).
17 42 C.F.R. § 431.242(b); 10 S.C. Code Ann. Regs. 126-158 (2012).
18 42 C.F.R. § 431.242(e); 10 S.C. Code Ann. Regs. 126-158 (2012).
19 42 C.F.R. § 431.242(d); 10 S.C. Code Ann. Regs. 126-158 (2012).
20 42 C.F.R. § 431.242(c); 10 S.C. Code Ann. Regs. 126-158 (2012).
21 42 C.F.R. § 431.244(a).
22 42 C.F.R. § 431.244.
23 42 C.F.R. § 431.232(d).
24 42 C.F.R. § 431.230(b).

This publication provides legal information, but is not intended to be legal advice. The information was based on the law at the time it was written. As the law may change, please contact the P&A for updates.

This publication is funded by the U.S. Department of Health and Human Services (Health Resources and Services Administration and the Administration on Intellectual and Developmental Disabilities) and the U.S. Department of Education (Rehabilitation Services Administration). It does not necessarily represent the official views of the funding

P&A does not discriminate on the basis of disability, race, color, creed, national origin, ethnicity, ancestry, citizenship, age, religion, sex or sexual orientation, veteran status or any other class by law in the provision of its programs or services. Pete Cantrell is P&A’s designated coordinator for Section 504 of the Rehabilitation Act of 1973 and the
Americans with Disabilities Act. [July 2014—Medicaid]

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