5101:6-3-01 Grounds for requesting a state hearing.

(A) The grounds for requesting a state hearing in the public assistance, food stamp, and social services programs 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.

(6) A request for prior authorization of a medical service or additional therapeutic leave days has been denied.

(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 mental retardation and developmental disabilities.

(9) A managed care plan has proposed or acted to enroll or continue an individual’s enrollment in a controlled substance and member management program.

(10) A managed care plan has denied a controlled substance and member management program member’s request to change a designated medical assistance provider.

(11) The agency has denied payment for a medical service provided to an individual enrolled in the primary alternative care treatment (PACT) program by a nondesignated provider.

(12) The individual believes that the reviewing agency’s decision on a request for precertification of a hospital admission or medical procedure is not correct.

(13) The individual disagrees with the denial of a request for just cause termination of managed care plan membership.

(14) A managed care plan has denied, proposed to reduce, suspend or terminate, or denied payment for a medicaid-covered service or the individual believes that the managed care plan has failed to act upon a request for such service with reasonable promptness.

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 must first pursue the issue through the managed care plan’s grievance process.

(15) The individual disagrees with any decision, action, or lack of action involving assistance under the supplemental security income (SSI) case management program.

(16) A regular employee believes that the assignment of an Ohio works first (OWF) work activity participant violates the prohibition against displacement.

(17) The agency has determined that the assistance group has failed to submit a timely application for recertification for food stamps or to appear for an interview scheduled after the assistance group timely filed its application for recertification.

(18) The agency has denied or delayed replacement of food stamp benefits.

(19) 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.

(20) 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.

(d) Community spouse and institutionalized spouse total gross income.

(e) Spousal share of assessed resources.

(f) Current countable resources.

(g) Community spouse resource allowance.

(B) 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.

(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.

(D) In the public assistance and social services programs, 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.

(E) Except as noted in paragraph (A)(13) of this rule, the right to a state hearing is limited to actions by ODJFS, the local agency, or an agent of ODJFS or the local agency.

Effective: 09/01/2008

R.C. 119.032 review dates: 05/30/2008 and 09/01/2013

Promulgated Under: 119.03

Statutory Authority: 3125.25, 5101.35

Rule Amplifies: 3125.25, 5101.35, 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, 6/1/97, 6/1/03, 5/31/04