5101:6-2-40 State hearings: coordinated services program state hearing and notice requirements.

(A) The purpose of this rule is to describe the process by which the Ohio department of

medicaid (ODM) or a medicaid managed care plan (MCP), as described in rule 5160-26-01 of the Administrative Code, informs an individual of notice and hearing rights for the medicaid coordinated services program (CSP).

(B) Definitions.

(1) "Authorized representative" means a person, eighteen years or older, who stands in place of the individual. The authorized representative may include a legal entity. ODM may request proper identification from the authorized representative.

(2) "Coordinated services program (CSP)," has the same meaning as described in rule 5160-20-01 of the Administrative Code.

(3) "Individual," for the purpose of this rule, means a recipient who is currently receiving medicaid services, either through fee-for-service or through an MCP.

(4) "Designated pharmacy" has the same meaning as described in rule 5160-20-01 of the Administrative Code.

(5) "Designated provider" has the same meaning as described in rule 5160-20-01 of the Administrative Code.

(C) Proposed enrollment into the CSP.

(1) Not less than fifteen days before enrolling the individual into the CSP, ODM or the MCP shall provide written notice, or its electronic equivalent, to the individual of the proposed enrollment into the CSP. The notice shall contain clear and understandable information describing:

(a) The effective date of the proposed enrollment into the CSP;

(b) The reason why ODM or the MCP is proposing enrollment;

(c) The appropriate Administrative Code citation(s) supporting the decision of ODM or the MCP;

(d) Where to get additional information regarding enrollment into the CSP, including the phone number for and availability of free legal services;

(e) Hearing rights as described in division 5101:6 of the Administrative Code, including the individual's rights to appeal the proposed enrollment through a state hearing; and

(f) The method of and deadline for selecting a designated provider or pharmacy; otherwise, a designated provider or pharmacy will be selected by ODM or the MCP.

(2) If the individual requests a state hearing and the hearing request is received by either ODM or the MCP within the fifteen-day prior notice period set forth in rule 5101:6-4-01 of the Administrative Code, ODM or the MCP shall enroll an individual into the CSP no sooner than the hearing decision mail date.

(D) Continued enrollment into the CSP.

(1) ODM or the MCP shall provide written notice, or its electronic equivalent, to the individual of the continued enrollment into the CSP. The notice shall contain clear and understandable information describing:

(a) The effective date of the continued enrollment into the CSP;

(b) The reason why ODM or the MCP is continuing enrollment;

(c) The appropriate Administrative Code citation(s) supporting the decision of ODM or the MCP;

(d) Where to get additional information regarding continued enrollment into the CSP, including the phone number for and availability of free legal services; and

(e) Hearing rights as described in division 5101:6 of the Administrative Code, including the individual's right to appeal the continuing enrollment through a state hearing.

(2) The individual requesting a timely hearing regarding continued enrollment into the CSP shall continue to be enrolled in the CSP until the hearing decision is rendered in accordance with rule 5101:6-4-01 of the Administrative Code.

(E) Denial of designated provider or pharmacy.

(1) ODM or the MCP shall provide written notice, or its electronic equivalent, to the individual when the individual's request for a designated provider or pharmacy change is denied. The notice shall contain clear and understandable information describing:

(a) The name of the denied designated provider or pharmacy;

(b) The reason why ODM or the MCP is denying the request for a change;

(c) The appropriate Administrative Code citation(s) supporting the decision of ODM or the MCP;

(d) Where to get additional information regarding the denial of the designated provider change, including the phone number for and availability of free legal services, and

(e) Hearing rights as described in division 5101:6 of the Administrative Code, including the right to appeal the denial through a state hearing.

(2) The individual requesting the hearing regarding the denial of designated provider or pharmacy change shall continue assignment with the current designated provider or pharmacy until the hearing decision is rendered in accordance with rule 5101:6-4-01 of the Administrative Code.

Effective: 02/28/2014
R.C. 119.032 review dates: 11/18/2013 and 02/01/2019
Promulgated Under: 119.03
Statutory Authority: 5101.35 , 5164.02 , 5164.758
Rule Amplifies: 5101.35 , 5160.011 , 5164.02 , 5164.758 , 5167.03 , 5167.10 , 5167.12 , 5167.13
Prior Effective Dates: 9/1/76, 4/1/80, 10/1/81, 5/1/82, 7/1/82, 4/1/83, 9/24/83, 11/1/83 (Temp), 12/1/83, 1/1/84, 3/1/84 (Temp), 6/1/84, 10/3/84 (Emer), 12/22/84, 4/1/86, 4/1/87, 9/1/87, 7/1/88 (Emer), 9/25/88, 2/1/90, 6/1/93, 6/1/03, 9/1/08, 5/1/09, 8/1/10, 7/1/11 (Emer), 1/1/12