(A) The right to a state hearing is limited to actions by the Ohio department of job and family services (ODJFS), the local agency, or an agent of ODJFS 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.
(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, 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 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 pharmacy or provider.
(10) In regard to actions involving a medicaid managed care plan:
(a) The individual disagrees with one of the following actions taken by a medicaid managed care plan:
(i) The denial or limited authorization of a requested service, including the type or level of services.
(ii) The reduction, suspension, or termination of services prior to the individual receiving the services previously authorized by the plan.
(iii) The failure to act on a request for services within the timeframe set forth in rule 5101:3-26-03.1 of the Administrative Code.
(iv) 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 pharmacy or provider.
(v) The plan's upholding the denial of payment for a medical service for which the individual is being billed.
(b) The right to a state hearing applies only to action or lack of action by the managed care plan. If the action or lack of action with which the individual disagrees is by the individual's physician or another sub-contracting provider, the individual may instead pursue the issue through the managed care plan's grievance process.
(c) The individual disagrees with a decision of ODJFS 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.
(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.
(C) The grounds for requesting a state hearing in the child support (Title IV-D of the Social Security Act) program, by an applicant, recipient, or custodial parent are as follows:
(1) An application for child support services has been denied, acted upon erroneously, or not acted upon with reasonable promptness.
(2) A recipient of child support services, believes the case has been acted upon erroneously, or not acted upon with reasonable promptness.
(3) The recipient believes that the child support enforcement agency (CSEA) has failed to use appropriate establishment or enforcement techniques.
(4) The custodial parent believes that child support collections have not been distributed or disbursed correctly or questions the accuracy of the arrears owed to ODJFS at termination of cash benefits.
(5) The custodial parent believes that child support payments, including payments owed to the custodial parent due to agency error, are not being issued with reasonable promptness.
(6) The custodial parent believes that the CSEA has failed to take action against an employer for failure to promptly forward payments withheld from the absent parent's wages.
(7) The custodial parent disagrees with the results of an investigation concerning termination of a support order.
(8) The custodial parent disagrees with the CSEA's decision to close the child support case.
(D) The grounds for requesting a state hearing in the child support program by the noncustodial parent are as follows:
(1) Services for establishing paternity have been denied.
(2) The CSEA has refused to review the noncustodial parent's support order for modification.
(3) The noncustodial parent disagrees with the results of an investigation concerning termination of a support order.
R.C. 119.032 review dates: 10/14/2011 and 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 3125.25, 5101.35
Rule Amplifies: 3125.25, 5101.35, 5111.085, 5111.179, 5126.055
Prior Effective Dates: 6/28/76, 9/1/76, 10/1/78, 12/1/79, 6/1/80, 6/2/80, 9/19/80, 10/1/81, 2/1/82, 4/1/82, 5/1/82, 10/1/82, 1/1/83, 1/17/83, 4/1/83, 7/1/83, 11/1/83 (Temp), 12/1/83, 3/1/84 (Temp), 6/1/84, 5/1/85 (Emer), 7/1/85 (Emer), 7/30/85, 9/29/85, 4/1/86, 4/1/87, 4/1/89, 12/1/89 (Emer), 3/22/90, 10/1/90, 10/1/91, 6/1/93, 2/1/95, 6/1/97, 10/1/97 (Emer), 12/30/97, 5/15/99, 6/1/03, 5/31/04, 9/1/08 , 8/1/10, 7/1/11 (Emer)
(1) A "request for a state hearing" is defined as a clear expression, by the individual or authorized representative, to the effect that he or she wishes to appeal a decision or wants the opportunity to present his or her case to a higher authority. The request may be either oral or written.
A state hearing may only be requested by or on behalf of an individual applying for or receiving benefits. A state hearing may not be requested by the local agency, the state agency, or another entity, such as a managed care plan, acting for or in place of the local or state agency.
(2) Oral requests for a hearing shall immediately be converted to a written record by the person to whom the request is made. It is not appropriate to require the individual to submit a written request once the desire for a hearing has been expressed orally. Requests made by telephone must be made by the individual.
(3) Written authorization must accompany all requests made on an individual's behalf by an authorized representative except:
(a) Upon a showing that such authorization cannot be obtained because of the individual's death or incapacity, and that the representative is, in fact, acting in the individual's best interest.
Example: A person who made initial application for the individual and whom the agency has always considered to be the individual's authorized representative.
(b) That attorneys may make a written hearing request on an individual's behalf without written authorization.
Written authorization is still required for access to case record documents and if the attorney or representative appears for the hearing unaccompanied by the individual.
(c) That an individual's spouse or minor individual's parent or legal guardian may request a hearing on behalf of the individual without written authorization.
(d) That a provider of long-term care may request a hearing, without obtaining written authorization, to contest the level of care assigned to the individual.
(B) Time limit
(1) The individual shall be allowed ninety calendar days to request a hearing on any action or inaction.
In the food assistance program, "action" shall include denial of a request for restoration of benefits lost more than ninety days but less than a year prior to the request for restoration.
(2) The ninety-day period begins on the day after the date the notice of action is mailed. The date of the hearing request is the date it is received by either the state or local agency.
(3) The ninety-day time limit does not apply unless the individual has received notice of hearing rights relative to the specific action or inaction being appealed, as specified in Chapter 5101:6-2 of the Administrative Code.
(4) Individuals who receive a resource assessment must request a hearing on the assessment no later than ninety days following the mailing date of the notice of approval or denial of the medicaid application.
(5) In the food assistance program, the assistance group may request a hearing at any time within the certification period to dispute its current level of benefits.
(C) The freedom to request a state hearing shall not be limited, interfered with, or discouraged in any way. This applies not only to the local and state agency but also to entities, such as managed care plans, acting for or in place of the local or state agency. Local and state agency emphasis shall be on helping the individual to submit and process the request, and to prepare for the hearing.
(D) In the food assistance program, if the assistance group making the hearing request speaks a language other than English, and the local agency is required by rule 5101:4-1-05 of the Administrative Code to provide bilingual staff or interpreters who speak the appropriate language, the local agency shall ensure that the hearing procedures are explained orally in that language.
(E) Complaints concerning discrimination because of age, race, sex, religion, national origin, political beliefs, or handicap shall be referred to the Ohio department of job and family services (ODJFS) equal employment opportunity (EEO) officer for investigation.
If the complaint also concerns one of the issues listed in rule 5101:6-3-01 of the Administrative Code, it shall also be considered a state hearing request.
R.C. 119.032 review dates: 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 3125.25, 5101.35
Rule Amplifies: 3125.25, 5101.35
Prior Effective Dates: 6/28/76, 9/1/76, 10/1/78, 12/1/79, 6/1/80, 6/2/80, 9/19/80, 10/1/81, 2/1/82, 4/1/82, 5/1/82, 10/1/82, 1/1/83, 1/17/83, 4/1/83, 7/1/83, 11/1/83 (Temp), 12/1/83, 3/1/84 (Temp), 6/1/84, 5/1/85 (Emer), 7/1/85 (Emer), 7/30/85, 9/29/85, 4/1/86, 4/1/87, 4/1/89, 12/1/89 (Emer), 3/22/90, 10/1/90, 10/1/91, 6/1/93, 6/1/97, 6/1/03, 9/1/08