Part 3: How to Advocate for Your Rights  

Federal law allows people receiving Medicaid to appeal or challenge decisions that deny, terminate, or reduce their services. This appeal process is called a Fair Hearing. Medicaid must send a letter, called a “notice,” about the decision. The agency must mail this notice at least 10 days before the decision takes effect.

The notice should include:

• Details about the decision
• The effective date of the decision
• The reason for the decision
• The law or policy that supports the decision
• Information about your right to appeal
• How to keep receiving services during the appeal process

If your services are going to change but you did not receive a written notice, immediately ask your case manager for a letter explaining the changes.

To start the appeal process, you or your representative (an attorney, friend, family member, or other spokesperson) must send a written request to the address below within 30 daysof receiving the written notice.(See Appendix) Please attach a copy of the written notification you received with your appeal request.  In your request for a fair hearing, you must clearly state what issues you wish to appeal.

Division of Appeals and Hearings

Department of Health and Human Services

P.O. Box 8206

Columbia, SC  29202-8206

The decision will be final if you do not request an appeal within 30 days of receiving the written notification. A request for a fair hearing is considered filed if postmarked within 30 days of receiving notice. The Division of Appeals and Hearings will inform you in writing about the status of your request within 10 days.

You may be eligible to keep receiving Medicaid benefits while waiting for the hearing decision.  If you want continued benefits, you must request this in writing when you file your appeal.  You should also contact your case manager within 10 calendar days of the notice date.  If the hearing decision is not in your favor, you may have to repay Medicaid benefits you received during the appeals process.

For more information, read the DRSC Factsheet on Medicaid Fair Hearings. You can also contact Disability Rights South Carolina to see if we can assist you with your appeal. 

Department of Health and Human Services Waiver Appeals

If you are found ineligible for waiver services under a waiver run by DHHS the process is the same as the Medicaid appeal above.

Office of Intellectual and Developmental Disabilities Waiver Appeals

If you receive a decision from OIDD that reduces your level of care or services, the written notice must explain why services are being denied or reduced. The notice should also explain your right to appeal or challenge the decision through the Medicaid appeal process. 

If you disagree with the decision, send an appeal letter to the Office Director of the Office of Intellectual and Developmental Disabilities within 30 days, explaining why you feel the decision was incorrect, previous efforts you have taken to resolve the complaint, and what outcome you are seeking. You may request that current services continue while your appeal is being reviewed, but you should make that request within 10 days.  You may be responsible for repayment of these services if you lose your appeal. Ask your case manager to explain this process if you have concerns about repayment. If you do not receive a written decision on your appeal within 30 days, contact your case manager to check the status. 

If you receive an unfavorable decision from the Office Director, you may appeal the decision in writing to the SC Department of Health and Human Services within 30 days and contact us at DRSC for possible representation.