Ohio Administrative Code
Title 5101:6 - Hearings
Chapter 5101:6-2 - Notice
Section 5101:6-2-40 - State hearings: coordinated services program state hearing and notice requirements
Universal Citation: OH Admin Code 5101:6-2-40
Current through all regulations passed and filed through September 16, 2024
(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)
"Designated pharmacy" has the same meaning as described
in rule
5160-20-01
of the Administrative Code.
(4)
"Designated
provider" has the same meaning as described in rule
5160-20-01
of the Administrative Code.
(5) "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.
(C) Proposed enrollment into the CSP.
(1)
ODM or the MCP
shall provide written notice, or its electronic equivalent, not less than
fifteen days before their 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.
(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.
(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.
(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.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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