Montana Fair Hearing and Medicaid Appeal Through the Office of Administrative Hearings

When You Need a Montana Fair Hearing

For many DPHHS decisions, including Medicaid eligibility, DDP eligibility, and waiver services, you have a right to a fair hearing before the Montana Office of Administrative Hearings (OAH). This is a formal administrative appeal — not a court proceeding, but a legally binding process conducted by a hearing officer who is independent of the agency that made the original decision.

Fair hearings cover decisions made by the Office of Public Assistance (Medicaid eligibility), the Developmental Disabilities Program (DDP eligibility, waiver services), and other DPHHS divisions. They do not cover SSI or SSDI decisions — those are appealed through the SSA's own reconsideration and hearing process.

The Deadline

For most Medicaid cases, a written request must be received by DPHHS or the Office of Public Assistance within 90 days of the negative action. The notice itself must tell you that you have the right to appeal and explain how to do it. For another DPHHS program, follow the deadline in that program's notice. If you did not receive a written notice, or if the notice did not include appeal rights information, document that — it is relevant to the hearing.

Call OAH at (406) 444-2470 for general instructions, or submit a written request to the Office of Administrative Hearings, P.O. Box 202922, Helena, MT 59620. You can also request a hearing through your local Office of Public Assistance.

Aid Paid Pending — Benefits Continue During the Appeal

For a timely Medicaid hearing request filed between the notice date and the effective date, benefits generally continue at the existing level while the appeal is pending, subject to exceptions in the notice and applicable rules. This is called "aid paid pending" (sometimes called "continuing benefits during appeal").

The distinction is critical. If DPHHS sends a notice on August 1 saying your Medicaid will terminate on September 1, and you request a fair hearing on August 20, your Medicaid stays active through the hearing process. If you wait until September 5, benefits have already been cut and you are asking for restoration — a much harder position.

This is why you should read every notice from DPHHS carefully and immediately. The effective date of the adverse action is the deadline that matters for aid paid pending, not the 90-day general appeal window.

How the Hearing Works

Fair hearings in Montana follow a structured process:

1. Request. Submit a written request by mail or through OPA. Include the specific action you are appealing, the date of the notice, and why you believe the decision was wrong.

2. Pre-hearing preparation. OAH schedules the hearing under federal and state timeframes; Medicaid cases are generally finalized within 60–90 days. You have the right to review your case file and all documents the agency relied on. You can bring witnesses, submit evidence, and be represented by an attorney or advocate — though an attorney is not required.

3. The hearing itself. Hearings are conducted by a hearing officer and may be held in person, by telephone, or by video. Both sides present evidence, testimony, and argument about the adverse action.

4. The decision. The hearing officer issues a written decision. If the decision is in your favor, DPHHS must comply. If the decision goes against you, the order states the applicable next-review route and deadline; most appeals must be filed within 15 days, and some cases allow 30 days.

Common Fair Hearing Scenarios for Families in Transition

For families navigating the adult disability transition, several situations commonly trigger fair hearing requests:

Medicaid termination at age 19. When a young adult ages out of HMK Plus (children's Medicaid) at 19, the transition to adult Medicaid is supposed to be seamless — but gaps happen. If you receive a notice that Medicaid is terminating and you believe the individual qualifies under the HELP Act, ABD pathway, or 1634 automatic enrollment, file for a fair hearing and request aid paid pending.

DDP eligibility denial. If the DDP Eligibility Specialist denies clinical eligibility, you can challenge the determination at a fair hearing. Bring the diagnostic evaluation, Vineland results, and any additional clinical evidence that supports the eligibility criteria under Mont. Code Ann. § 53-20-202(3).

0208 waiver service reductions. If DDP reduces the hours or types of services in an existing waiver service plan, the agency must provide a written notice explaining why. You can challenge the reduction through a fair hearing and request continuation under the applicable rules; continuation may keep services at the prior level while the appeal is pending.

Medicaid spend-down miscalculation. If the Office of Public Assistance calculates your medically needy spend-down amount incorrectly — counting income that should be excluded or failing to credit qualifying medical expenses — a fair hearing can correct the error.

Fair Hearings vs. SSA Appeals

Montana fair hearings cover state-administered benefits (Medicaid, DDP, 0208 waiver). Federal SSI and SSDI decisions are appealed through SSA's own process — first through reconsideration (Form SSA-561), then before an Administrative Law Judge, then the Appeals Council, then federal court.

If a young adult loses SSI and Medicaid simultaneously, two separate appeals may be needed — one through SSA for the SSI decision and one through OAH for the Medicaid decision. The timelines and procedures are different, and missing one does not excuse missing the other.

The Montana SSI at 18 & Adult Benefits Guide walks through both appeal tracks with deadlines, forms, and contact information for OAH and SSA, plus letter templates for requesting benefit continuation within the 10-day SSI window.

See more Montana guides →