What Happens If Medicaid Reduces Your Services?

If Louisiana Medicaid reduces a service you are already receiving, you may have the right to appeal the decision.

A reduction could involve fewer personal-care hours, a decrease in an authorized service, removal of part of a Plan of Care, or another change that results in receiving less Medicaid-covered assistance than before.

A reduction does not necessarily mean the decision is final.

Louisiana Medicaid members have appeal rights when services are denied or reduced, and participants in Louisiana Home and Community-Based Services (HCBS) waivers also have rights to challenge certain reductions or terminations of services.

However, appeal procedures and deadlines can differ depending on:

• The service involved
• Whether the service is provided through an OAAS or OIDD waiver
• Whether the service is provided through a Medicaid health plan
• Whether the action involves a current authorization or a request for a new authorization
• The date shown on the written notice
• Whether the participant wants currently authorized services to continue while the appeal is reviewed

Important: This article provides general educational information only. It is not legal advice and does not determine whether a particular Medicaid decision is correct, whether an appeal should be filed, whether services will continue during an appeal, or what the outcome of an appeal will be. Always follow the instructions and deadlines contained in the actual notice you receive.

Do You Have the Right to Appeal a Medicaid Service Reduction?

Generally, yes.

Louisiana Medicaid identifies the right to appeal decisions affecting Medicaid services as an important member right.

For Louisiana HCBS waiver participants, state waiver materials specifically recognize the right to request a fair hearing when services are:

• Denied
• Suspended
• Terminated
• Reduced
• Discontinued
• Not acted upon with reasonable promptness

Louisiana’s current OIDD waiver materials also identify an involuntary reduction of a support or service as a decision that can be challenged through the administrative appeal process.

OAAS participant rights materials similarly state that a participant has the right to appeal if they are told that services will be reduced, stopped, or that a requested service will not be provided.

What Should You Receive Before Services Are Reduced?

For many adverse Medicaid decisions, the participant should receive a written notice explaining the action.

The notice may tell you:

• What service is being reduced or denied
• When the change is expected to take effect
• Why the decision was made
• What appeal rights are available
• How to request an appeal or fair hearing
• The deadline for requesting the appeal
• Whether and how currently authorized services may continue while the appeal is pending

Read the entire notice carefully.

The deadlines in the notice are important.

Do not assume that the deadline to appeal and the deadline to request continued services are necessarily the same.

What Should You Do When You Receive a Reduction Notice?

A practical first step is to review the notice and identify exactly what Medicaid is changing.

Ask:

1. Which service is being reduced?
2. How much is being reduced?
3. When is the reduction supposed to begin?
4. What reason does the notice give?
5. What deadline does the notice give for an appeal?
6. Does the notice explain whether existing services can continue during an appeal?

Keep the original notice.

It may also be useful to gather records related to the service, such as the current Plan of Care, prior service authorization, assessment information, medical documentation, or other records relevant to the person’s current needs.

Gathering information does not mean the participant must appeal. It simply helps the person understand the decision and the options identified in the notice.

Can Your Services Continue While You Appeal?

Sometimes, but not automatically.

This is one of the most important parts of the appeal process.

Louisiana and federal Medicaid rules provide circumstances in which a participant may be able to request that previously authorized services continue while an appeal or fair hearing is pending.

But continuation of benefits has specific requirements.

For example, under Louisiana’s current Medicaid managed-care rules, continuation generally applies only when the appeal involves the termination, suspension, or reduction of a previously authorized service, the existing authorization has not expired, and the request for continuation is made within the required timeframe.

Louisiana’s HCBS waiver procedures also contain protections allowing currently authorized waiver services to remain in place in certain circumstances when an appeal is filed timely.

An appeal by itself should not be assumed to automatically continue services.

The participant should carefully follow the continuation-of-benefits instructions included with the adverse-action notice.

Timing can be especially important because the period for preserving existing services may be shorter than the overall period available to challenge the decision.

Is an Expired Authorization the Same as Medicaid Reducing a Service?

Not always.

This distinction is important.

Suppose someone was authorized for a particular service for six months and that authorization reaches its scheduled expiration date.

A new request for another authorization period may be treated differently from Medicaid ending or reducing an authorization before the existing authorization expires.

Louisiana’s current managed-care guidance specifically distinguishes between:

• Reducing, suspending, or terminating a previously authorized course of treatment, and
• An authorization simply reaching the end of its approved period or amount

That distinction can affect whether continuation-of-benefits protections apply.

The same caution should be used when discussing renewals, reauthorizations, and new service requests.

Do not assume that every denial of additional or renewed services creates an automatic right to continue the previous level of services.

The notice and the rules for the particular Medicaid program should be reviewed.

What If Only Part of the Requested Service Was Approved?

An appeal does not require Medicaid to have denied everything.

Louisiana Medicaid states that members may request an appeal when:

• All requested services were denied
• Part of the requested services was denied
• Different services were offered instead
• The provider did not request the full amount of services the participant believes was needed

For example, if a request was made for a particular amount of medically necessary support and Medicaid authorized a smaller amount, appeal rights may be available.

Whether an appeal is appropriate in an individual situation depends on the actual decision and notice.

What Is a State Fair Hearing?

A State Fair Hearing is an administrative process through which an impartial hearing official reviews a Medicaid decision being challenged.

For applicable Louisiana Medicaid appeals, hearings are handled through the Louisiana Division of Administrative Law (DAL).

A participant may generally:

• Present information related to the decision
• Have a representative assist them
• Submit relevant records or documentation
• Participate in the hearing
• Receive a decision through the administrative process

A participant may choose to have another person assist or represent them, subject to the applicable procedures.

That person could potentially include a family member, authorized representative, advocate, or attorney.

What If the Service Is Through a Medicaid Health Plan?

The process can be different when the service is administered through a Louisiana Medicaid managed-care health plan.

Louisiana Medicaid currently instructs members with health-plan decisions to generally use the health plan’s appeal process first.

The health plan’s written decision should explain:

• How to request an appeal
• Applicable deadlines
• How to request an expedited appeal when available
• Whether continuation of benefits may be available
• How to request a State Fair Hearing after the health-plan appeal process when applicable

The participant should follow the instructions provided by the health plan rather than assuming that the waiver or fee-for-service appeal procedure applies.

What About EPSDT Services?

Children and young adults under age 21 receiving Medicaid may receive services through EPSDT, but the appeal pathway can depend on how the particular service is administered.

Louisiana’s current EPSDT Support Coordination guidance distinguishes between:

• Fee-for-Service Medicaid decisions, and
• Medicaid Managed Care decisions

The handbook instructs EPSDT Support Coordinators to explain appeal rights and offer assistance when a denial is received.

Continuation-of-benefits rules also differ depending on the type of decision and how the service was authorized.

For this reason, an EPSDT family should use the actual denial or reduction notice to determine:

• Who issued the decision
• Where the appeal must be submitted
• The applicable deadline
• Whether existing services may continue

EPSDT does not create one universal appeal deadline for every service.

What About OIDD Waiver Services?

Participants receiving Louisiana OIDD waiver services—including services through the:

• New Opportunities Waiver
• Residential Options Waiver
• Supports Waiver
• Children’s Choice Waiver

have established rights concerning adverse waiver decisions.

Current Louisiana OIDD waiver materials recognize the right to request a fair hearing concerning decisions that include a reduction or termination of services.

OIDD waiver procedures also provide advance-notice and appeal protections when the state proposes to reduce or terminate waiver services.

Because continuation of an existing service can depend on how quickly the appeal is requested, participants should review the notice immediately rather than waiting until the proposed reduction takes effect.

What About OAAS Waiver Services?

OAAS participants also have appeal protections.

Current OAAS Waiver Rights and Responsibilities materials specifically state that a participant may appeal if:

• They are told they will no longer receive a service
• They are told they cannot receive a requested service
• Their services will be reduced

OAAS identifies the Division of Administrative Law as the entity that conducts applicable fair hearings.

Participants should follow the instructions in the specific OAAS notice because the timeframe for maintaining existing services while an appeal is pending can depend on when the appeal is filed.

Can a Support Coordinator Help?

A Support Coordinator can be an important resource when a participant receives a service reduction or denial.

Depending on the program and circumstances, Support Coordination may include helping the participant:

• Understand what the notice says
• Understand the appeal process described in the notice
• Identify relevant records
• Obtain available Plan of Care or Support Coordination documentation
• Communicate with appropriate Medicaid or program entities
• Navigate required Medicaid processes

Louisiana’s EPSDT guidance specifically instructs Support Coordinators to explain appeal rights and offer assistance after certain service denials.

Louisiana’s HCBS waiver materials also contemplate Support Coordinator involvement in providing relevant documentation and information associated with an appeal.

However:

A Support Coordinator does not decide the appeal.

A Support Coordination Agency also should not promise that an appeal will succeed, provide legal representation unless independently authorized and qualified to do so, or tell a participant that services are guaranteed to continue.

The appeal or fair-hearing decision is made through the applicable Medicaid, health-plan, or administrative process.

What Information May Be Relevant to an Appeal?

The information relevant to a Medicaid service decision depends on why the service was reduced.

Depending on the service, relevant records may include:

• The written Medicaid or health-plan notice
• Current and previous service authorizations
• Plan of Care information
• Current assessments
• Medical records
• Physician or other qualified-provider documentation
• Documentation of functional needs
• Information concerning changes in the participant’s condition
• Other records directly related to the Medicaid decision

The goal should be to provide accurate information about the participant’s actual needs and circumstances.

Participants and providers should never create, exaggerate, or alter documentation in an attempt to obtain a particular Medicaid outcome.

What If You Need Help Understanding Your Rights?

Louisiana Medicaid provides information about appeals and State Fair Hearings through its official Medicaid website.

The Louisiana Division of Administrative Law handles applicable State Fair Hearings.

Current OAAS participant-rights materials list the Division of Administrative Law at: 225-342-5800

Louisiana Medicaid also identifies Disability Rights Louisiana as a resource that may provide assistance with Medicaid appeals: 1-800-960-7705

Whether a particular organization can provide representation or assistance will depend on its own eligibility and case-acceptance requirements.

The Bottom Line

What happens if Louisiana Medicaid reduces your services?

You may have the right to challenge the decision through an appeal or State Fair Hearing.

A service reduction should not automatically be treated as a final decision that cannot be questioned.

However, several details matter:

• Read the written notice carefully.
• Identify the exact service and amount being reduced.
• Pay close attention to all deadlines.
• Determine whether the service is through a waiver, fee-for-service Medicaid, or a Medicaid health plan.
• Do not assume that filing an appeal automatically keeps services in place.
• If continued services are important, review the notice immediately for the specific requirements and deadline for requesting continuation of benefits.
• Keep copies of the notice and relevant service records.
• Ask for assistance understanding the process when needed.

Most importantly, the rules can differ depending on the Medicaid program and type of decision.

The written notice issued for the specific reduction should be treated as the primary source for the participant’s appeal instructions and deadlines.

Important Information: This article is provided solely for general educational and informational purposes. It is not legal advice, Medicaid eligibility advice, medical advice, or individualized guidance concerning an appeal or State Fair Hearing. Nothing in this article determines whether a Medicaid decision is correct, guarantees a right to continuation of services, establishes an appeal deadline for a particular case, or predicts the outcome of an appeal. Appeal procedures, deadlines, continuation-of-benefits requirements, and available review processes can vary depending on the program, service, type of decision, health plan, authorization period, and individual circumstances. Participants should follow the instructions and deadlines contained in the actual written notice they receive and consult the appropriate Medicaid, health-plan, or administrative authority regarding their individual case.

Our agency is an independent Louisiana Support Coordination Agency and is not the Louisiana Department of Health, Louisiana Medicaid, the Division of Administrative Law, a Medicaid managed-care organization, or another government agency. A Support Coordinator may assist participants in understanding and navigating applicable processes within the scope of Support Coordination but does not decide Medicaid appeals or guarantee their outcome.