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Make a Complaint or Ask for a Fair Hearing About Long-Term Care Services

Make a Complaint or Ask for a Fair Hearing About Long-Term Care Services

Make a Complaint

Medicaid has specially trained people responsible for answering your questions about Florida Medicaid, including complaint resolution. As a health plan member, you may submit a complaint against your SMMC plan by contacting the Medicaid Help Line toll free at 1-877-254-1055 (8:00 a.m. ET - 5:00 p.m. ET Monday - Friday), Telecommunications device for the deaf (TDD) 1-866-467-4970 or by filing a Medicaid Complaint.

Ask for a Fair Hearing About Your Long-Term Care Services

After individuals are enrolled in the LTC program, if they have been turned down for a Medicaid service, or were receiving a Medicaid service, but it was reduced or stopped, they should receive a letter explaining why Medicaid will not pay for or cover the service.  When this happens, enrollees may have the right to a Medicaid Fair Hearing.

Persons enrolled in a Medicaid health plan, must go through the plan’s appeal process [ pdf 308.2 kB ] before they can have a Medicaid Fair Hearing. The letter to enrollees explaining why Medicaid will not pay for or cover the service is called a Notice of Adverse Benefit Determination and it tells enrollees how to ask for a plan appeal. Enrollees can also call the plan [ pdf 59.5 kB ] to get more information.

Requests for a Fair Hearing may be turned down if they are made before the plan’s appeal process is finished. When the plan’s appeal process is finished, the enrollee will receive a letter to explaining the plan’s decision. This letter is called a Notice of Plan Appeal Resolution.  Enrollees can request a Medicaid Fair Hearing if the plan’s decision is not in their favor.

You can ask for a Fair Hearing by calling the Medicaid Helpline at 1-877-254-1055 (TDD 1-866-467-4970), or in writing by:

When asking for a Fair Hearing, please the enrollee should include his or her name, phone number, mailing address, and email (if available).  The name of the Medicaid enrollee, their Medicaid ID number and some details about the services that were denied, reduced or stopped must be provided.   Any notices related to the Hearing Request may also be submitted.  It is also important to tell the Agency the preferred method of contact: mail or email.

Important note about email communication – The Agency must encrypt all emails to protect enrollees’ personal information.  If email is the preferred method of contact, the Agency will send encrypted emails.  This means an enrollee will need to create a password to open the email.  Please read the encryption instructions [ pdf 658.5 kB ] for more information.

The Office of Fair Hearings will review the enrollee’s Fair Hearing request and send a letter confirming that the Fair Hearing request was received.  This letter has important information about the Fair Hearing process and instructions for communicating with the Office of Fair Hearings.  The Office of Fair Hearings will send more information during the Fair Hearing process.  It is very important that enrollees read all documents sent by the Office of Fair Hearings and carefully follow the instructions.

Please read the Medicaid Fair Hearing [ pdf 1.2 MB ] brochure for more information about Medicaid Fair Hearings.

Frequently Asked Questions

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