Ohio Administrative Code › Title 5101:6 - Hearings › Chapter 5101:6-3 - Request for a State Hearing › Section 5101:6-3-01 - State hearings: grounds for requesting a state hearing

Current through all regulations passed and filed through July 1, 2024
(A) The right to a state hearing is limited
			 to actions by the Ohio department of job and family services (ODJFS), the Ohio
			 department of medicaid (ODM), the local agency, or an agent of ODJFS, ODM, or
			 the local agency. A hearing need not be granted when a change in state or
			 federal law, or local agency policy adopted pursuant to options authorized in
			 state law, requires automatic adjustments of benefits for classes of
			 recipients. If the reason for the request is the misapplication of the change
			 to the appellant's individual circumstances, hearing rights exist. The closure
			 of fair hearing benefits is not grounds for requesting a state hearing nor
			 subject to notice rights.
(B) The
			 grounds for requesting a state hearing in regard to family services program
			 benefits are as follows:
(1) An application
			 for benefits has been denied, acted upon erroneously, or not acted upon with
			 reasonable promptness.
(2) The
			 agency has proposed or acted to reduce, suspend, terminate,
			 expunge, or withhold benefits, or the assistance
			 group believes that the level of benefits is not correct.
(3) A request for an adjustment in benefits
			 has been denied, not acted upon, acted upon erroneously, or not acted upon with
			 reasonable promptness.
(4) The
			 agency has determined that an overpayment or overissuance has occurred, or the
			 assistance group believes that the amount of the overpayment or overissuance is
			 not correct.
(5) The individual
			 disagrees with any decision, action, or lack of action involving work
			 registration exemption status or requirements, or work activity exemption
			 status or participation.
A regular employee believes that the assignment of an Ohio
				works first (OWF) work activity participant violates the prohibition against
				displacement.
(6) A request
			 for prior authorization of a medical service or additional therapeutic leave
			 days has been denied, or the individual believes that the reviewing agency's
			 decision on a request for pre-certification of a hospital admission or medical
			 procedure is not correct.
(7) The
			 individual or provider of long-term care believes that the level of care
			 assigned, or the effective date of the level of care assigned, to the
			 individual is not correct.
(8) The
			 individual disagrees with a preadmission screening or resident review
			 determination made by the Ohio department of mental health and addiction
			 services or the Ohio department of developmental disabilities.
(9) The enrollment or decision to continue
			 enrollment of the individual in the coordinated services program (CSP), or
			 denial of the individual's request to change a CSP-designated
			 provider.
(10) In regard to actions
			 involving a medicaid managed care plan (MCP) or "MyCare Ohio" plan (MCOP):
(a) The individual disagrees with one of the
			 following actions taken by a medicaid managed care plan:
(i) An MCP or MCOP appeal resolution decision
			 based on an adverse benefit determination, as described in rules
			 5160-26-08.4 or 5160-58-08.4 of the Administrative Code,
			 as applicable.
(ii) A managed care
			 plan's enrollment or decision to continue enrollment of the individual in the
			 coordinated services program (CSP), or denial of the individual's request to
			 change a CSP-designated provider.
(iii) The plan's upholding the denial of
			 payment for a medical service for which the individual is being
			 billed.
(b) The
			 individual disagrees with a decision of ODM that the individual does not meet
			 an exclusion from mandatory managed care plan membership, or a decision to deny
			 the individual's request for just cause termination of membership in an
			 assigned managed care plan and enrollment in a different managed care
			 plan.
(c) The MCP or MCOP fails to
			 adhere to the notice and timing requirements for appeals set forth in rule
			 5160-26-08.4 or 5160-58-08.4 of the Administrative
			 Code.
(11) The agency
			 has denied payment for a medical service provided to an individual enrolled in
			 the coordinated services program (CSP) by a nondesignated provider.
(12) The individual disagrees with any
			 decision, action, or lack of action involving assistance under the supplemental
			 security income (SSI) case management program.
(13) The individual feels that a county board
			 that has medicaid local administrative authority under division (A) of section
			 5126.055 of the Revised Code for
			 home and community-based services violated the right of an individual to choose
			 a provider that is qualified and willing to provide services to the
			 individual.
(14) In the medicaid
			 program, either the institutionalized spouse or the community spouse may
			 request a hearing concerning the following determinations:
(a) Community spouse monthly income
			 allowance.
(b) Community spouse's
			 minimum monthly maintenance needs allowance.
(c) Family allowance.
(d) Community spouse and institutionalized
			 spouse total gross income.
(e)
			 Spousal share of assessed resources.
(f) Current countable resources.
(g) Community spouse resource
			 allowance.