What to Do If Your Indiana Medicaid Home Care Services Are Denied

Finding out that Medicaid home care services have been denied can be stressful for families. You may have been counting on help with bathing, dressing, meals, mobility, or other daily activities. Now you may be wondering how your loved one will receive the support they need.

If this happens to your family, do not assume the decision is final.

In Indiana, Medicaid members have the right to challenge certain decisions about their eligibility, healthcare coverage, and approved services. Depending on the type of denial, you may be able to request an appeal, ask for a review, or provide additional information to support your case.

Understanding what to do next can help you protect your loved one's rights and explore available options.

Here is what Indiana families should know.

1. Understand Why the Home Care Services Were Denied

Before taking action, find out exactly why the request was denied.

Medicaid home care services may be denied, reduced, or delayed for several reasons, including:

• Eligibility requirements: The individual may not meet the financial or program eligibility requirements.

• Level of care: The assessment may determine that the individual does not meet the required level of care for the requested waiver services.

• Medical necessity or support needs: The documentation submitted may not adequately explain why the requested services are needed.

• Incomplete paperwork: Required documents, assessments, or forms may be missing.

• Service authorization: The requested service, amount of care, or number of hours may not have been approved.

• Provider requirements: The provider may not meet the requirements for the particular Medicaid service.

The denial notice should explain the decision and provide information about the member's appeal rights.

Read the notice carefully. Pay attention to the reason for the denial, the date of the decision, the deadline to appeal, and where the appeal must be sent.

2. Request a Copy of the Denial and Review the Details

Keep a copy of the denial letter and any documents related to the request.

If the explanation is unclear, contact the agency or health plan that issued the decision.

Ask questions such as:

• What specific requirement was not met?

• Was the decision based on financial eligibility, an assessment, or service authorization?

• Was any information missing from the application?

• Can additional documentation be submitted?

• What is the deadline for requesting an appeal?

• Will previously approved services continue while the appeal is pending?

Do not rely only on a phone conversation. Ask for important explanations and decisions in writing whenever possible.

3. Know Which Type of Medicaid Decision You Are Appealing

Not all Medicaid denials follow the same process.

In Indiana, the next step depends on the type of decision.

If Medicaid eligibility was denied:

If the Division of Family Resources (DFR) denied the Medicaid application or changed the person's eligibility, follow the appeal instructions in the notice. Families can contact DFR at 800-403-0864 for assistance.

If a PathWays health plan denied or reduced a service:

If your loved one is enrolled in Indiana PathWays for Aging and the health plan denied a requested service, contact the health plan and follow its member appeal process.

If a waiver eligibility decision was denied:

If the decision concerns eligibility for a Medicaid waiver, review the notice for the appeal deadline and instructions. Indiana's Office of Administrative Law Proceedings handles applicable FSSA fair hearing matters.

The distinction is important because contacting the wrong office or using the wrong process may delay your request.

4. File an Appeal Before the Deadline

If you disagree with the decision, you may have the right to request an appeal.

Do not wait until the last minute. The deadline depends on the type of decision and the notice you received.

For Indiana PathWays members, the 2026 model handbook explains the appeal process and states that members generally have 120 calendar days after the problem occurred or is scheduled to occur to file an appeal. However, other plan-level appeal deadlines and specific notice instructions may apply.

For Medicaid eligibility decisions and other FSSA actions, follow the deadline stated in the official notice.

When submitting an appeal, include:

• The Medicaid member's full name

• Medicaid identification information, if requested

• A copy of the denial notice

• The date of the decision

• A clear explanation of why you disagree

• Supporting documents, if available

• Contact information for the member or authorized representative

Keep copies of everything you submit. If you send the appeal by mail, fax, or email, keep proof of submission.

5. Gather Documents That Support Your Request

Supporting documentation can help explain why the requested services are important.

Depending on the situation, useful documents may include:

• Recent medical records or relevant provider statements

• Functional or care assessments

• Documentation of mobility limitations

• Information about assistance needed with daily activities

• Medication and treatment information relevant to the request

• Records of falls or safety concerns

• A list of services requested and why they are needed

• Previous care plans or service authorization documents

For example, if a family is requesting additional personal care hours, documentation should clearly explain which daily activities the individual cannot safely complete without assistance.

Be specific. Instead of simply saying that a loved one needs more help, describe the daily challenges, the type of assistance required, and what may happen without adequate support.

Only submit information relevant to the decision being appealed, and protect private health information when sharing documents.

6. Contact Your Indiana PathWays Health Plan

If your loved one is enrolled in PathWays for Aging, contact the health plan listed on their Medicaid information.

Indiana's PathWays health plans include:

• Anthem: 833-412-4405

• Humana: 866-274-5888

• UnitedHealthcare: 800-832-4643

Ask to speak with Member Services or the department that handles appeals.

Explain that you received a denial or reduction of home care services and want to understand the appeal process.

Ask the representative to explain:

• The reason for the decision

• How to file an appeal

• The exact deadline

• Whether an expedited appeal is available if the situation is urgent

• Whether existing services can continue during the appeal

• How to submit additional supporting documents

Write down the date of the call, the representative's name, and any reference number provided.

7. Request a State Fair Hearing When Applicable

If you disagree with an applicable FSSA decision or an appeal outcome, you may have the right to request a State Fair Hearing.

A fair hearing gives the individual an opportunity to explain why they believe the decision was incorrect and present supporting evidence.

Indiana's Office of Administrative Law Proceedings (OALP) handles applicable FSSA appeals.

Contact Information:

Office of Administrative Law Proceedings – FSSA Hearings

Email: fssa.appeals@oalp.in.govPhone: 317-234-3488 or 1-866-259-3573Fax: 317-232-4412

Mailing address:

Office of Administrative Law Proceedings – FSSA Hearings100 N. Senate Avenue, Suite N802Indianapolis, IN 46204

Always check the instructions and mailing address on the specific notice you received before submitting documents.

You may represent yourself or have an authorized representative assist you. If someone else is filing or speaking on your behalf, the required authorization may need to be provided.

8. What If Your Loved One's Current Home Care Services Are Being Reduced or Stopped?

A denial of new services is different from a decision to reduce or terminate services your loved one already receives.

If the health plan intends to reduce or stop previously approved care, review the notice immediately.

For PathWays members, the 2026 model handbook explains that members receiving ongoing services should receive advance notice before certain services are stopped. It also describes circumstances in which members may request continued services while an appeal is pending.

However, continued services are not automatic in every situation. The timing of the appeal and the instructions in the notice matter. If the appeal is unsuccessful, the member may be responsible for the cost of services received during the appeal period.

Contact the health plan as soon as possible and ask whether services can continue while the appeal is reviewed.

If the person depends on daily assistance, also discuss a temporary care plan with family members and their healthcare team.

9. What If the Appeal Is Still Denied?

An unfavorable appeal decision does not necessarily mean there are no further options.

Depending on the type of decision and the member's program, additional review may be available.

The Indiana PathWays 2026 model handbook describes a State Fair Hearing after the health plan appeal process and an external review by an Independent Review Organization in applicable cases.

Ask the health plan or the office handling the decision to explain the next available review option and its deadline.

You may also consider contacting an Indiana legal aid organization or an attorney familiar with Medicaid and long-term care matters if you need help understanding your rights.

10. Explore Other Support Options While You Wait

The appeal process can take time. Meanwhile, families may still need help caring for an aging loved one.

Depending on eligibility and availability, Indiana families can explore:

• Local Area Agency on Aging resources

• Family Caregiver Support Program services

• Community meal programs

• Transportation assistance

• Respite resources

• Private-pay home care options

• Other community-based senior support programs

You can contact the INconnect Alliance at 800-713-9023 to ask about local aging and caregiver resources.

Remember that alternative programs have their own eligibility requirements, funding limitations, and service availability.

A Helpful Checklist for Families

If your loved one's Indiana Medicaid home care services are denied, use this checklist to organize your next steps:

• Read the denial notice carefully.

• Identify the reason for the denial.

• Determine whether the decision came from DFR, FSSA, or a PathWays health plan.

• Check the appeal deadline.

• Contact the appropriate office or health plan.

• Gather relevant supporting documents.

• Submit the appeal using the instructions provided.

• Keep copies and proof of submission.

• Ask whether existing services can continue during the appeal.

• Explore temporary support options if care is needed immediately.

  
  

Frequently Asked Questions

Can I appeal an Indiana Medicaid home care denial?

Yes. Indiana Medicaid members have appeal rights for certain decisions involving eligibility, healthcare coverage, and services. The process depends on the type of decision.

How long do I have to appeal a Medicaid denial in Indiana?

There is no single deadline for every type of Medicaid decision. Follow the deadline stated in your denial notice. The Indiana PathWays 2026 model handbook describes a general 120-calendar-day period for certain appeals, but health plan and eligibility appeal rules may differ.

Can my loved one's home care continue during an appeal?

In certain circumstances, members may request continuation of previously approved services while an appeal is pending. Specific conditions and deadlines apply. Contact the health plan immediately to confirm whether continued services are available.

Can a family member file an appeal for an aging parent?

A family member or other representative may assist with an appeal when the appropriate authorization is provided. The required documentation depends on the circumstances.

Who can help me understand a Medicaid denial in Indiana?

You can contact the Division of Family Resources for eligibility decisions, your loved one's PathWays health plan for service decisions, or the Office of Administrative Law Proceedings for applicable FSSA hearing questions.

Helping Indiana Families Navigate Home Care Options

A Medicaid denial can leave families feeling confused and worried about their loved one's future care. But understanding the reason for the decision, reviewing the appeal instructions, and gathering the right information can help families take informed next steps.

At Nurtured Home Care Indiana, we understand that finding reliable care and support for an aging loved one is important.

Our team is here to help families explore home care options and discuss their caregiving needs.

If you are looking for support for a loved one in Fort Wayne, Elkhart, or surrounding Indiana communities, reach out to our team.

Nurtured Home Care Indiana

Phone: (260) 418-9911

Website: www.nhcindiana.com

Supporting Families Every Step of the Way.

Disclaimer: This article is for general educational purposes only and is not legal advice or a guarantee of Medicaid eligibility, service approval, or appeal outcomes. Medicaid rules, appeal deadlines, and procedures may vary depending on the program and type of decision. Always review the official notice and confirm current requirements with Indiana Medicaid, FSSA, or the member's health plan.