Current through all regulations passed and filed through September 16, 2024
(A) When a request for a state hearing is
received by the state, a managed care plan (MCP), a "MyCare Ohio" plan (MCOP),
or local agency within the
fifteen-calendar day prior notice period,
benefits shall not be reduced, suspended, or terminated until a state hearing
decision is rendered unless one of the following occurs:
(1) A determination is made at the hearing
that the sole issue is one of state or federal law, and not one of fact or
judgment.
(2) The appeal is
withdrawn or abandoned pursuant to rule
5101:6-5-03 of the
Administrative Code.
(3) A change
affecting the assistance group's eligibility or level of benefits occurs while
the decision is pending and the assistance group fails to timely request a
hearing upon receipt of the subsequent notice of adverse action.
(4) A mass change that adversely affects an
assistance group's eligibility for
the supplemental nutrition
assistance program (SNAP) or basis of issuance occurs while the hearing
decision is pending.
(5) The
assistance group specifically waives continuation of
SNAP
benefits.
The section for requesting a state hearing on the prior notice
contains a space for the assistance group to indicate whether it desires to
waive continued food assistance benefits. If the assistance group does not
positively indicate that it waives continued benefits, the local agency shall
assume that continued benefits are desired.
(6) The assistance group's
SNAP certification period expires. Further entitlement
to
SNAP benefits cannot be established without
recertification based upon a new application as provided in rule
5101:4-7-07 of the
Administrative Code.
(7) The
assistance group's learning earning and parenting (LEAP) supportive services,
and support services provided to participants in a work activity under the Ohio
works first (OWF) program, or the
SNAP employment and training
program are being reduced or terminated.
(8) The MCP or MCOP member specifically
waives continuation of medicaid benefits.
(9) The MCP or MCOP continues the provision
of medical
services, and the member receives the services
previously requested by the provider and authorized by the MCP or MCOP before
the hearing decision is rendered. Further entitlement to medical services
cannot be established without a provider requesting additional services and the
MCP or MCOP making a medical necessity determination.
(10) If, upon the expiration of a period of
authorized service, the enrollee requests further services, denial of that
request shall be considered a denial, rather than a reduction, suspension, or
termination, of service and continuation of benefits will not apply.
(B) When benefits are reduced,
suspended, or terminated in violation of the provisions of paragraph (A) of
this rule, benefits shall be reinstated to the previous level.
(C) When the request for a state hearing is
received by the state or local agency within ten calendar days after the
effective date of the adverse action (the ten-day time limit does not apply
to
SNAP
), and
when good cause is shown for the delay in making the request, benefits shall be
reinstated to the previous level. "Reinstatement of benefits to the previous
level" means that benefits shall be reinstated retroactive to the date the
benefits were reduced, suspended, or terminated.
(1) "Good cause" is defined as death in the
immediate family, sudden illness, or injury of the individual or a member of
the individual's immediate family, or other circumstances that reasonably
prevented requesting a hearing within the timely notice period.
(2)
SNAP benefits shall not be
reinstated when the assistance group has specifically waived continuation of
benefits, or when the certification period has expired.
(D) When an adverse action was taken without
prior notice, pursuant to paragraph (A) of rule
5101:6-2-05 of the
Administrative Code, and when the hearing request is received by either the
state or local agency within fifteen calendar days from the mailing date of the
notice of adverse action, benefits shall be reinstated to the previous
level.
(E) When
SNAP benefits are reduced or terminated because of a
mass change, and when the assistance group's hearing request is received by
either the state or local agency within fifteen calendar days from the mailing
date of the mass change notice,
SNAP benefits shall be
reinstated to the previous level if the following conditions are met:
(1) The reason for the assistance group's
appeal is an erroneous application of the mass change to the individual
case.
(2) The assistance group does
not specifically waive its right to continuation of benefits.
(3) The
SNAP certification period has
not expired.
(F) If the
need for reinstatement is discovered by the local agency, the local agency
shall authorize reinstatement within one
workday of the date of discovery. If
the need for reinstatement is discovered by the bureau of state hearings, the
bureau shall immediately order the responsible agency to reinstate benefits.
All reinstatement orders shall be in writing. The agency shall respond to
reinstatement orders by authorizing benefits within one
workday of receipt of the order. Benefits so
reinstated shall continue until the state hearing decision is rendered unless
one of the conditions in paragraph (A) of this rule is met.
(G) MCP or MCOP issues.
(1) When a hearing request involves an
adverse benefit determination appeal resolution within the prior notice period,
as described in rule
5160-26-08.4 or 5160-58-
08.4 of the Administrative Code,
the MCP or MCOP shall be responsible for ensuring benefits are continued at or
reinstated to the previous level until the services that were authorized by the
MCP or MCOP are received or until the state hearing decision is issued,
whichever date comes first.
(2)
Service shall be continued or reinstated when a timely hearing request is
received unless the appellant's physician certifies, in writing to the bureau
of state hearings, that continuation of the service would pose a substantial
risk of adverse health consequences.
(3) Nothing in this rule shall require an
individual physician to continue a service for an enrollee if that physician
believes that to do so would violate the provisions of section
4731.22 of the Revised
Code.
(4) When a hearing request
involving an MCP or MCOPs proposed enrollment in the coordinated services
program (CSP), defined in rule
5160-20-01 of the Administrative
Code, is received by the state or local agency within the prior notice period,
the MCP or MCOP will not enroll the member in the CSP until the state hearing
decision is issued.
(5) MCPs and
MCOPs are not required to provide continuation of benefits except for the
reasons outlined in paragraphs (G)(1) and (G)(4) of this rule.
(H) The denial or delay of
replacement
SNAP benefits, under the provisions of rule
5101:4-7-11 of the
Administrative Code and paragraph (A)(1)(a) of rule
5101:6-5-02 of the
Administrative Code, shall remain in effect pending the state hearing decision.
When a nonadverse action is required, the agency shall proceed with that
action. In the child support program, the child support enforcement agency
(CSEA) shall continue to provide services, as otherwise appropriate, without
regard to any hearing requests that have been made.
(I) When a hearing request involving ODJFS's
proposed enrollment in the CSP, defined in rule
5160-20-01 of the Administrative
Code, is received by the state or local agency within the prior notice period,
ODJFS will not enroll the individual in the CSP until the state hearing
decision is issued.
