Medicaid Expansion Health Coverage: Denials and Legal Actions

Medicaid expansion was designed to reduce the coverage gap for adults and improve health coverage. This would ultimately aid individuals receiving more benefits than the appropriate amount to qualify under conventional Medicaid regulations. 

What is Medicaid Expansion and Why Denials Happen

Under the Affordable Care Act (ACA), Medicaid expansion permits states to provide Medicaid coverage to low-income adults. Prior to the Affordable Care Act, Medicaid only covered a small number of individuals. These included low-income families, pregnant women, and individuals with disabilities. Now, because of the ACA, states are allowed to broaden their coverage to all adults earning up to 138% of the Federal Poverty Level (FPL).

Although there is an expansion of Medicaid, individuals can still be denied services at times.

• Increase in Income
  1. Individuals earning above the income threshold are not eligible.
  2. Individuals who misreport their income or do not provide all their sources of income.
• Residency of Citizenship Status
  1. Medicaid is typically accessible to U.S. citizens, with the exception of some immigrants who meet specific qualifications.
  2. Immigrants who are undocumented are not eligible for Medicaid Expansion unless under emergency circumstances.
• Lack of Expansion in the State
  1. Certain states, such as Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming, are known as non-expansion states. An individual who lives in a non-expansion state cannot receive the benefits of Medicaid Expansion.
• Failure to Provide Documentation
  1. Documents such as proof of income, identity, or residency that are missing or cannot be provided will result in the denial of Medicaid benefits for the individual.

Legal Grounds for Challenging a Denial

1. Right to Appeal
   1. Under the Federal Law, applicants have the right to a “Fair Hearing”. Applicants should request a hearing within 30 to 90 days, depending on the state in which they reside. The state’s Medicaid agency or Office of Administrative Hearings usually handles the hearing. Individuals should come prepared to present the appropriate evidence, bring witnesses, and may be represented by an attorney.
2. Violations of Federal Law
   1. Improper denial of eligibility contrary to meeting the requirements (i.e., income & residency)
   2. Discriminatory practices (denying individuals based on age, disability, or language barriers)
3. Due Process Violations (14th Amendment)
   1. Must notify the individual in writing of the denial
   2. Explain to the individual the reason for the denial
   3. Inform the individual of their right to appeal
4. Disability-Related Discrimination
   1. Americans with Disabilities Act (ADA)
   2. Section 504 of the Rehabilitation Act
      1. Both of these forms/services grant individuals the right to file claims when they are denied Medicaid Expansion.
5. Class Action Lawsuits
   1. Individuals can file class action lawsuits when issues such as wrongful denials or delays arise. These can include delays in processing one’s application and/or the systemic denial of benefits for eligible individuals (e.g., foster children, disabled adults)

Appealing a Medicaid Denial: Step-by-Step Guide

If you are an individual denied Medicaid expansion services, there are steps you can take to potentially become eligible. Appealing a Medicaid denial does not guarantee that you will receive the services, but it can be beneficial if done correctly. 

1. Read the denial notice and decide whether or not to appeal
2. Request a fair hearing
3. Continue your coverage (only if applicable)
4. Prepare and attend the fair hearing
5. Wait for a decision

Filing a Civil Claim Against a Government Agency

You are eligible to file a civil claim against a government agency for the following reasons: 

• Violated your constitutional rights
• Unlawfully denied you benefits
• Discriminated against you
• Failed to comply with federal Medicaid Law

How KAASS LAW Can Help

If you’ve been denied Medicaid expansion services, you may be feeling discouraged and angry. KAASS LAW can help you understand your legal options and take the necessary action. Our attorneys are prepared to assist with appeals, discrimination claims, or any wrongful denials of benefits. KAASS LAW is dedicated to assisting individuals in navigating the legal system and securing the compensation they deserve. 

Health care is a necessity. If you or a loved one is struggling to receive Medicaid coverage, we encourage you to contact our office to discuss your situation. Call KAASS LAW at (844) 522-7752 today.