5160-26-08.5 Managed health care programs: responsibilities for state hearings.

(A) MCPs must develop and implement written policies and procedures that ensure the MCP's compliance with the applicable state hearing provisions specified in division 5101:6 of the Administrative Code, including but not limited to:

(1) MCPs must notify members of their right to a state hearing as specified in paragraph (H) of rule 5101:3-26-08.4 of the Administrative Code. Members or their authorized representatives may request a state hearing within ninety calendar days by contacting the ODJFS bureau of state hearings or local agency. The ninety-day period begins on the day after the mailing date on the state hearing form.

(2) Following the bureau of state hearings' notification to the MCP that a member has requested a state hearing the MCP must:

(a) Complete the "Appeal Summary for Managed Care Plans" (JFS 01959, rev. 06/03) with appropriate attachments, at least three business days prior to the scheduled hearing date. The appeal summary must provide all facts and documents relevant to the issue, and be sufficient to demonstrate the basis for the MCP's action or decision.

(b) Send a copy of the completed appeal summary to the appellant, assigned hearings section, local agency, and the designated ODJFS contact.

(c) Continue or reinstate the benefit(s) specified in rule 5101:6-4-01 of the Administrative Code, if the MCP is notified that the member's state hearing request was received within the prior notification period and the member requested that the benefits be continued.

(d) Not enroll the individual in the coordinated services program (CSP) if the MCP is notified that the member's state hearing request was received within the prior notification period.

(3) The parties to a state hearing include the MCP, member, member's authorized representative, and estate representative of a deceased member.

(4) MCPs must participate in the hearing in person or by telephone, on the date indicated on the "State Hearing Scheduling Notice" (JFS 04002, rev. 09/02) sent to the MCP by the bureau of state hearings.

(5) MCPs must comply with the state hearing officer's decision provided to the MCP via the "State Hearing Decision" (JFS 04005, rev. 03/03). If the hearing officer's decision is to sustain the member's appeal, the MCP must:

Complete the "State Hearing Compliance" form (JFS 04068, rev. 05/01). A copy of the completed form, including applicable documentation, is due by no later than the compliance date specified in the hearing decision to the bureau of state hearings and the designated ODJFS contact. If applicable, the MCP must:

(a) Authorize or provide the disputed services promptly and as expeditiously as the member's health condition requires.

(b) Pay for the disputed services if the member received the disputed services while the appeal was pending.

(B) Upon request, the MCP's state hearing policies and procedures must be made available for review by ODJFS.

Effective: 01/01/2012
R.C. 119.032 review dates: 09/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.16 , 5111.17 , 5111.085
Rule Amplifies: 5111.01 , 5111.02 , 5111.16 , 5111.17 , 5111.179
Prior Effective Dates: 7/1/03, 6/1/06, 9/15/08, 7/1/09, 8/1/10