(A) For the purpose of this rule:
(B) Every benefit recipient under the age of sixty annually shall be subject to a medical examination by HPRS' examining physician, unless the board's medical advisor certifies that a benefit recipient's disability is ongoing and the board waives the requirement that the benefit recipient undergo an annual medical examination.
(C) Every person under the age of sixty who is receiving disability benefits pursuant to section 5505.18 of the Revised Code shall annually submit a statement of earnings, an attending physician's report, and any other medical or employment information as deemed necessary by the executive director or medical advisor to determine whether the benefit recipient is still disabled as defined by section 5505.18 of the Revised Code. The board may waive the requirement to submit an annual statement of earnings or attending physician's report if the board's medical advisor certifies that a disability benefit recipient's disability is ongoing.
(1) The information required pursuant to paragraph (C) of this rule shall be submitted at a time designated by the executive director, and shall be reported on forms provided by HPRS.
(2) The information required pursuant to paragraph (C) of this rule shall be reviewed by the medical advisor. If the medical advisor determines the benefit recipient may no longer be disabled or if the benefit recipient has requested termination of benefits, HPRS shall:
(a) Schedule a medical examination with an examining physician recommended by the medical advisor.
(b) If the examining physician certifies the benefit recipient no longer meets the disability standards set forth in section 5505.18 of the Revised Code, HPRS staff and medical advisor shall present the benefit recipient's file to the board at the next available meeting. No additional information will be accepted from the benefit recipient accept as described in paragraph (E)(2) of this rule. Unless requested by the board, the benefit recipient may not appear before the board.
(3) The board shall review the examining physician's report and if it concurs with the examining physician's certification that the benefit recipient no longer meets the disability standards set forth in section 5505.18 of the Revised Code, the disability benefits shall terminate the earlier of:
(a) Thirty days after the board concurs with the examining physician's certification,
(b) Upon employment with the state highway patrol, or
(d) Notwithstanding paragraph (C)(3)(a) of this rule, disability benefits will terminate the earlier of sixty days after the board concurs with the examining physician's certification or upon employment with the state highway patrol if HPRS receives confirmation from the state highway patrol that the benefit recipient will be reinstated.
(D) The benefit recipient will be sent notification of the board's action no more than five days after the board meets and such notice will be sent by regular US mail to the benefit recipient's last known address. The notice will inform the benefit recipient of the date his or her benefits will terminate, if applicable, and his or her right to appeal.
(E) Within twenty days of the board's decision, the benefit recipient may file a written notice of appeal. The notice of appeal shall reference the decision being appealed and shall include the reason(s) why the decision is being appealed. If the benefit recipient does not file a notice of appeal as described in this rule, the board's determination made under paragraph (C) of this rule is final.
(1) The notice of appeal will be considered at the next regularly scheduled meeting of the board. Except as provided in this rule, benefits shall not be terminated while an appeal is pending.
(2) Within forty days of the board's determination made under paragraph (C) of this rule, the benefit recipient must file any evidence he or she would like considered by the board. New disabling conditions and the related medical evidence will not be considered. Extensions will only be granted if the benefit recipient can show, and the board chair concurs, that additional time is needed to obtain relevant new medical evidence and the process for obtaining that evidence is already in process. HPRS shall void the notice of appeal if new evidence is not received by HPRS in the time described in this paragraph.
(3) Copies of the reports of the examining physician and medical advisor will be sent to the member and the member's agent upon written authorization of the member, unless the release of such reports is otherwise prohibited by law. However, the medical advisor's recommendation will not be released until the board has made an initial decision regarding the member's disability benefits.
(4) The applicant has the right to appear at the hearing, with or without counsel, to present new testimony.
(5) Evidence, information, or other documentation not already submitted in accordance with this rule will not be permitted.
(6) The board's decision is final.
(F) Nothing in this rule or any waiver granted by the board shall waive any rights of HPRS to request the benefit recipient to undergo a medical examination if information is received at any time which indicates the benefit recipient may no longer be eligible for disability benefits.
(G) Any benefit recipient who desires to be reexamined in conjunction with a request to return to active duty status shall first be required to submit a medical examination report from a physician of his or her choice, which certifies that the benefit recipient is no longer eligible for disability benefits. The benefit recipient shall then be subject to the process described in paragraph (C) of this rule.
(H) Failure to comply with the provisions identified in this rule may result in the suspension of disability and healthcare benefits.
(1) Unless for good cause shown, the disability benefit recipient shall be presumed to have refused to submit to the medical examination by an examining physician if HPRS has scheduled such examinations two times and such disability benefit recipient has canceled, rescheduled, or failed to submit to such scheduled medical examinations.
(2) The refusal of a benefit recipient to submit to a medical examination or submit employment information requested pursuant paragraphs (B) and (C) of this rule shall result in the suspension of disability benefits and health care or prescription benefits selected by the disability benefit recipient, if any, upon thirty days prior written notice to the benefit recipient and shall continue until compliance.
(a) The suspension of disability and health care or prescription drug benefits selected by the disability benefit recipient, if any, shall be effective on the first day of the month immediately following the expiration of the aforementioned thirty day notice period.
(b) In the event the benefit recipient submits to the required medical examination or information after the aforementioned thirty day notice period, HPRS will reinstate the benefit recipient's disability and health care or prescription drug benefits selected by the benefit recipient, if any, on the first day of the month immediately following the benefit recipient's compliance.
Five Year Review (FYR) Dates: 05/18/2022
Promulgated Under: 111.15
Statutory Authority: 5505.07, 5505.18
Rule Amplifies: 5505.18
Prior Effective Dates: 2/15/1981, 1/1/1986, 11/2/1989, 10/1/1996, 3/28/2013, 11/17/2016