How to Appeal a Medicaid Home Care Denial in Pennsylvania

If your loved one was denied Medicaid home care services in Pennsylvania — or if the number of authorized hours feels inadequate — you do not have to accept that decision.  Pennsylvania Medicaid provides clear appeal rights, and in our experience at CareChoice, families who appeal with proper documentation win more often than they expect.

Here’s how the appeal process works, what strengthens your case, and what most
families get wrong.

Types of Denials You Can Appeal

There are three common scenarios that lead families to appeal.

Eligibility denial. Your loved one applied for home care services through Community
HealthChoices and was told they don’t meet the nursing-facility level of care. This
usually means the functional assessment scored their needs as insufficient for HCBS
services.

Insufficient hours. Your loved one was approved for services, but the care plan
authorizes fewer hours than the family believes are needed. This happens when the
assessment underestimates certain care needs — often because the care recipient
minimized their limitations during the evaluation, or because overnight and weekend
needs weren’t adequately documented.

Service reduction or termination. Your loved one was receiving services, and the
MCO reduced the authorized hours or terminated services based on a reassessment.
This triggers a notification and appeal rights.

In all three cases, the family has the right to challenge the decision.

Step 1: Request the Decision in Writing

If you haven’t already received a written notice, request one from the MCO. The notice
should include the specific reason for the denial or reduction, the regulation or policy
cited, and instructions for filing an appeal. This document is your starting point — the
appeal must respond to the specific rationale the MCO used.

Step 2: File a Grievance with the MCO

The first level of appeal is the MCO’s internal grievance process. Contact the MCO
(AmeriHealth Caritas, Keystone First CHC, or PA Health & Wellness) and file a formal
grievance. You typically have 30 days from the date of the adverse notice to file, though timelines can vary — check the notice for the specific deadline.

When filing, be specific. Don’t just say “we disagree.” Explain why the determination
doesn’t match your loved one’s actual daily needs. Provide supporting documentation
(more on this below). Request that the MCO reconsider the assessment or the
authorized hours.

In our experience, the MCO grievance process resolves a meaningful percentage of
disputes — particularly when the family provides medical documentation that wasn’t
available during the original assessment. If the initial assessor missed something, the
grievance reviewer may catch it when presented with additional evidence.

Step 3: Request a Fair Hearing

If the MCO grievance doesn’t resolve the issue, you can escalate to a Fair Hearing
through the Pennsylvania Department of Human Services. A Fair Hearing is an
administrative proceeding where an independent hearing officer reviews the case and
makes a binding decision.

To request a Fair Hearing, contact DHS or file through the MCO (they’re required to
provide instructions in the adverse notice). Fair Hearings can be conducted in person,
by phone, or by written submission.

The Fair Hearing process is more formal than the MCO grievance, but families do not
need a lawyer to participate. You present your case, the MCO presents theirs, and the
hearing officer decides. In our experience, the hearing officers take family testimony
seriously — a daughter describing in specific detail how she helps her mother bathe
every morning carries real weight.

What Strengthens Your Appeal

Medical documentation. Letters from your loved one’s physician describing functional
limitations, diagnoses that affect daily living, and the physician’s opinion on the level of
care needed. Doctor’s notes carry significant weight in both grievance and Fair Hearing
proceedings.

Hospital and rehab discharge records. If your loved one was recently hospitalized or
in rehab, discharge summaries that document ongoing care needs support the
argument that home care services are necessary.

Detailed caregiver testimony. A written statement from the family member who
provides daily care, describing in specific detail what a typical day looks like: which
activities require help, how long each takes, what happens when help isn’t available, and
any safety incidents (falls, missed medications, wandering) that have occurred. We help
families at CareChoice prepare these statements because they’re often the most
compelling piece of evidence — they describe reality in a way that a one-hour
assessment visit can’t always capture.

Medication list with context. A list of current medications, along with an explanation
of what happens when medications are missed or taken incorrectly. If your loved one
takes 12 medications and has been hospitalized twice due to medication errors, that’s
directly relevant to the number of care hours that should be authorized.

What We See in Practice

The families who win appeals at the highest rate share a common pattern: they
document everything before the appeal, not after. They keep a daily log of care
activities. They save medical records. They write down every fall, every missed
medication, every time their loved one couldn’t dress without help. When the appeal
comes, they have a binder, not just a memory.

We also see families lose appeals for preventable reasons. The most common: missing
the filing deadline. The 30-day window is firm. If you receive an adverse notice and you
disagree with it, file the grievance immediately — don’t wait to “think about it” and let
the deadline pass.

Another pattern: families accept the first denial without understanding they have a
second level of appeal. The MCO grievance is step one, not the only step. If the
grievance doesn’t work, the Fair Hearing is a separate proceeding with a separate
decision-maker. Many families don’t get that far simply because they didn’t know they
could.

Aid Pending: Protecting Your Services During the Appeal

If your loved one is already receiving services and the MCO issues a notice to reduce or
terminate those services, you may be able to request aid pending — meaning the
current level of services continues while the appeal is being decided. You must typically
file the appeal within 10 days of the adverse notice (not 30) to preserve aid pending.  Check the notice for the specific deadline.

This is critical for families who rely on the current care hours. Without aid pending,
services can be reduced while you’re still fighting the appeal. Filing quickly preserves
the status quo.

CareChoice Supports Families Through Appeals

CareChoice helps Philadelphia-area families prepare appeals, assemble supporting
documentation, and understand what the process involves. We don’t replace legal
representation — if your case is complex, an elder law attorney may be appropriate —
but we help ensure families don’t lose on a technicality or a missed deadline.

Talk to CareChoice → Contact our Philadelphia team

Written by Sophia Aloia, Content & SEO Manager | CareChoice Sophia covers Medicaid
home care policy and family caregiver advocacy across CareChoice’s markets.

Related: Functional Assessment in PA → | 5 Things Philly Families Get Wrong → | Who
Qualifies for Paid Family Caregiving? →