Two Kinds of Denials in PA Medicaid

When you apply for or receive home care through Medicaid, you might face a denial. The appeal process depends entirely on who denied you and what they denied.

An eligibility denial happens when the state decides you do not qualify for the Community HealthChoices (CHC) waiver. This decision comes from the Office of Long-Term Living (OLTL) or the County Assistance Office (CAO). It means they believe you do not meet the medical or financial eligibility rules.

A service denial happens when your chosen CHC plan (such as Keystone First or UPMC) refuses to approve a specific service. It also includes situations where the plan cuts your existing Personal Assistance Services hours. You appeal this directly with the plan first.

Appealing a CHC Waiver Eligibility Denial

If you receive a notice saying you do not qualify for the CHC waiver, you must appeal to a Department of Human Services (DHS) Fair Hearing. You have 30 days from the date on the notice to submit your appeal in writing.

If you already receive services and are found ineligible during a reassessment, you must appeal within 15 days to keep your services in place. The hearing takes place by phone or in person before an Administrative Law Judge. If you disagree with the judge’s decision, you can request reconsideration by the DHS Secretary or appeal to the Commonwealth Court.

Many medical eligibility denials happen because of limitations in the Functional Eligibility Determination (FED). The local Area Agency on Aging (PCA in Philadelphia) uses the FED to measure your hands-on help with ADLs like bathing, dressing, and toileting over the last three days.

However, the FED ignores skilled nursing needs and the need for supervision or cueing. According to the PHLP 2026 guide, people with cognitive impairment may be denied even when their needs are significant. If your loved one needs supervision or cueing to get through the day, consider appealing.

Need help gathering care records for an appeal? Call New Century Home Care at 215-974-0000 or fill out our form and select “I am a client” then “I need services.” Our office staff speaks English, Russian, and Ukrainian.

Appealing a Service Denial or Reduction in Hours

If your CHC plan denies a request for more hours or cuts your current hours, you must follow a specific process. A reduction in hours at reassessment is considered a service denial.

1. File a Grievance: You have 60 days from the date on the denial letter to file a grievance with your CHC plan. You can request this by calling the plan or returning the form included with your letter. If you want to keep your current hours during the review, you must ask for the grievance within 15 days.
2. Attend the Grievance Panel: A three-person panel, which includes a doctor from the plan, will review your case. You can participate by phone, video, or in person. Your own doctor can also participate. The plan must make a decision within 30 days.
3. Request an Expedited Grievance (if needed): If waiting 30 days would harm your health, your doctor can write a letter requesting an expedited grievance. The plan must then decide within 72 hours.
4. Request a Fair Hearing: If the grievance panel denies your request, you have 120 days to request a DHS Fair Hearing. You must ask within 15 days to keep your services in place. Send the form included with your grievance decision via certified mail. The hearing decision usually takes about 90 days. With a doctor’s letter, an expedited hearing decision takes 3 business days.
5. Request an External Review: You can also ask for an external review by an outside doctor chosen by the PA Insurance Department. You must ask your plan for this within 15 days of the grievance decision. Your services will continue, and a decision is made within 60 days.

You can request both a fair hearing and an external review at the same time. If either process results in a favorable decision for you, the CHC plan must approve the services.

Appeal Deadlines Cheat Sheet

Missing a deadline can end your right to appeal. Always check the date printed on your notice letter, as the clock starts on that date.

How to Build Your Case

PHLP recommends asking your doctor to take part in the grievance or to write a letter explaining why the service is medically necessary.

When you describe your needs, be specific. Do not just say your loved one needs help. Explain exactly what happens if they do not get help. Detail their need for supervision, cueing to complete tasks, and any behavioral symptoms like wandering or physical aggression.

Family caregivers can and should participate in the hearings. The caregiver is often the best person to explain the daily routine and the exact hands-on help required. You can bring notes to ensure you do not forget any details.

Always send your appeal forms by certified mail. Keep copies of everything you send and receive. That gives you proof you met each deadline. If you are still applying, see the CHC waiver application steps.

Free Help for PA Medicaid Appeals

You do not have to fight a denial alone. The Pennsylvania Health Law Project (PHLP) gives free legal advice, and in some cases representation, to people appealing OLTL waiver decisions. You can reach the PHLP Helpline at 1-800-274-3258.

The deadlines on this page come from PHLP’s How to Appeal a Denial in CHC (June 2024). For the bigger picture, see our PA Medicaid home care guide.

While New Century Home Care cannot provide legal representation, our team can help you gather service logs, care plans, and daily notes from the caregiver side to support your case.

For home care in Philadelphia and the four surrounding counties, call New Century Home Care at 215-974-0000 or submit our contact form (choose “I am a client” and “I need services”).