West Virginia DoHS Fair Hearing: How to Appeal a Medicaid Denial or Reduction

When to Request a Fair Hearing

A DoHS fair hearing is your administrative appeal right when the West Virginia Department of Human Services takes an adverse action against your adult child's Medicaid coverage. This includes denials of eligibility, reductions in covered services, termination of coverage, and failure to act on an application within the required timeframe.

The fair hearing is separate from SSA appeals. SSA handles SSI benefit denials through its own reconsideration and ALJ hearing process. The DoHS fair hearing covers state-administered Medicaid decisions — Medicaid eligibility outside the 1634 automatic enrollment, personal care services, and waiver service authorizations.

The Filing Deadline

You must submit a written request for a fair hearing within 90 days of receiving the adverse notice. Follow the notice's submission instructions; the request can be submitted through your local county DoHS office.

If you request the hearing before the effective date of the adverse action (the date the termination or reduction would take effect), your benefits continue at their current level until the hearing decision is issued. Miss that deadline, and the adverse action takes effect even though the hearing is still pending.

Preparing for the Hearing

The hearing is conducted by an impartial hearing officer, not a DoHS caseworker. You have the right to:

• Present documents, medical records, and written evidence
• Bring witnesses who can testify about your child's needs
• Have an attorney or advocate represent you
• Cross-examine DoHS witnesses
• Receive a written decision with an explanation of the reasoning

Bring every relevant document: the adverse notice itself, medical evaluations, current treatment records, the most recent Medicaid renewal correspondence, and any documentation showing that the denial or reduction is incorrect. If the dispute involves personal care service hours, bring caregiver logs and treating physician statements about the level of care required.

Waiver Service Authorization Appeals

If Acentra Health (the IDD Waiver utilization management contractor) reduces or denies a service authorization — cutting behavioral support hours, denying a requested environmental modification, or reducing day habilitation services — the appeal route is different from a standard DoHS fair hearing.

The case manager first submits an Exception Request through the CareConnection web portal. If Acentra denies the exception, the next step is a formal administrative review before the Acentra medical director. If that review does not resolve the dispute, follow Acentra's and BMS's notice for any further review or hearing.

Getting Representation

Legal Aid of West Virginia (1-866-255-4370) represents income-eligible residents in DoHS fair hearings. Disability Rights of West Virginia (800-950-5250) handles cases involving systemic rights violations and I/DD Waiver service denials.

The West Virginia Adult Disability Benefits Guide includes appeal timeline trackers and template letters for both DoHS fair hearings and waiver service authorization disputes.

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