Current through all regulations passed and filed through September 16, 2024
(A) An individual who disagrees with a state
hearing decision, or with a decision by the hearing authority to deny or
dismiss a hearing request, has the right to request an administrative appeal.
The administrative appeal process does not apply to
administrative disqualification hearing decisions.
An administrative appeal may only be requested by or on behalf
of an individual applying for or receiving benefits. An administrative appeal
may not be requested by the local agency, the state agency, or another entity,
such as a managed care plan or "MyCare Ohio" plan, acting for or in place of
the local or state agency.
The administrative appeal process is the responsibility of the
bureau of state hearings.
(B) Notice of the right to and the method of
obtaining an administrative appeal shall be included on the state hearing
dismissal notice, on the JFS 04005 "State Hearing Decision,"
and on the notice of failure to establish good cause for abandonment required
by rule
5101:6-5-03 of the
Administrative Code.
(C)
Administrative appeal requests
(1) A state
hearing decision, or a decision by the hearing authority to deny or dismiss a
hearing request, will be reviewed for one or more of the following reasons:
(a) The decision is contrary to the weight of
the evidence presented.
(b) A
prejudicial error was committed in the course of the proceedings.
(c) The decision relies on an incorrect
application of law or rule.
(d)
When a decision is regarding the prevention, retention and contingency (PRC)
program, the decision relies on an incorrect application of the following:
(i) The Ohio department of job and family
services (ODJFS) model design, developed under section
5108.03 of the Revised Code, if
the county department of job and family services (CDJFS) involved adopted it;
or
(ii) CDJFS's written statement
of policies adopted under section
5108.04 of the Revised Code and
any amendments the CDJFS has adopted to the statement.
(2) A "request for an
administrative appeal" is defined as a clear expression, by the individual or
authorized representative, to the effect that he or she wishes to appeal a
state hearing decision or a decision of the hearing authority to deny or
dismiss a state hearing request.
(3) The request must be in writing and signed
by the individual or authorized representative.
Written authorization must accompany all requests made on the
individual's behalf by an authorized representative, unless the representative
was the authorized representative of record at a previous stage in the
proceedings, or unless one of the conditions described in rule
5101:6-3-02 of the
Administrative Code is met.
(4) The request must be received by the
bureau of state hearings, within fifteen calendar days from the date the
decision being appealed was issued.
(D) Continuing assistance
The filing of an administrative appeal request will not
automatically stay implementation of the initial state hearing decision,
denial, or dismissal. However, the bureau of state hearings may choose to
exercise the department's inherent authority to delay implementation of a
decision when an administrative appeal appears to be meritorious and when the
appeal cannot be processed to completion in time to prevent loss of benefits to
the individual. In these situations, the bureau of state hearings shall issue a
written directive to the local agency, with a copy to the individual and to the
appropriate office. Such an interim order, either to stay implementation or to
reinstate assistance, shall not constitute a decision on the merits of the
appeal, but only serves to preserve the status quo until a decision on the
merits can be made.
(E)
Dismissal
(1) An administrative appeal request
may be dismissed because:
(a) It is not made
by the individual or authorized representative, as required by paragraph (C)(3)
of this rule.
(b) It is not timely,
as defined by paragraph (C)(4) of this rule.
(2) The bureau of state hearings shall
provide written notice of dismissal to the individual and authorized
representative. Copies shall be provided to the local agency for inclusion in
the case file and to the appropriate office.
(F) Docketing
Once an administrative appeal request has been accepted, the
bureau of state hearings shall docket the appeal, assigning it to an
administrative appeal hearing examiner.
(G) If the administrative appeal hearing
examiner determines that the original decision and the appeal request do not
contain sufficient information upon which to decide the appeal, the official
hearing record and/or the recording of the hearing may be reviewed. The hearing
examiner will not convene a new hearing.
(H) Administrative appeal hearing examiners
Administrative appeals shall be assigned to and decided by an
impartial administrative appeal hearing examiner who has no personal stake or
involvement in the case and was not directly involved in the initial decision
being appealed.
This person shall be an attorney assigned to the bureau of
state hearings and delegated authority by the ODJFS director.
Decisions of the hearing examiner shall be subject to approval
by the ODJFS director or a designee.
(I) Administrative appeal decisions
(1) After reviewing the initial decision, the
individual's appeal request, and the hearing record and/or recording if
appropriate, the hearing examiner, subject to review and approval in accordance
with paragraph (H) of this rule, shall issue an administrative appeal decision
which addresses the issues of fact and law raised in the appeal
request.
(2) Administrative appeal
decisions shall be issued within fifteen calendar days from the date of the
administrative appeal request.
(3)
The administrative appeal decision shall affirm the initial decision when the
hearing examiner determines that the initial decision contains no error
affecting the outcome of the appeal (except as noted in paragraph (I)(6) of
this rule).
(4) The administrative
appeal decision shall reverse the initial decision when the hearing examiner
determines that the initial decision contains an error which resulted in an
outcome adverse to the individual. Administrative appeal decisions which
reverse the initial decision shall contain instructions concerning corrective
action and shall require compliance via JFS 04068 "Order of Compliance Notice"
when appropriate.
(5) The administrative appeal decision shall
vacate the initial decision and remand the case to the original hearing officer
when the hearing examiner determines that the record developed does not contain
sufficient information to decide the appeal.
(a) If benefits were continuing due to a
timely hearing request, an administrative appeal decision that vacates the
original decision and remands the case to the hearings section has the effect
of preserving or reactivating the individual's procedural right to continuation
of benefits. The agency is responsible for responding immediately to a vacate
and remand decision and ensuring that benefits are continued. If the original
decision has been implemented, the agency shall immediately reinstate benefits
to the previous level.
(b) If the
factual determination for which the case is being remanded can be made by
reviewing the existing hearing record, a supplemental hearing is not necessary.
If the existing record is not sufficient, a supplemental hearing shall be
convened. If the administrative appeal decision specifically requires the
convening of a supplemental hearing, that order shall be followed.
(c) Supplemental hearings shall be scheduled
on a priority basis. Written notice shall be provided and shall be accompanied
by a copy of the administrative appeal decision and any further instructions
necessary to ensure that all parties understand the purpose and scope of the
supplemental hearing.
(d) If the
individual or authorized representative fails, without good cause, to appear
for a supplemental hearing, the hearing officer shall review the existing
hearing record to determine if the facts for which the case was remanded are
already established therein.
(i) If so, a
supplemental decision shall be issued, clearly indicating that a supplemental
hearing was scheduled but the individual did not appear, that the record was
reviewed, and that the necessary additional facts were established from that
review. This shall be followed by the appropriate conclusions of policy and
recommendations based on those facts.
(ii) If some or all of the additional facts
cannot be established from the record, a supplemental decision shall be issued,
clearly indicating that the individual did not appear for the supplemental
hearing and that the hearing record was reviewed but was silent as to one or
more of the factual issues for which the case was remanded. This shall be
followed by the appropriate conclusions of policy and recommendations based on
the facts that are available.
(iii) If the individual does not appear for
the supplemental hearing, no discussion of the merits of the appeal shall occur
between the hearing officer and the agency.
(6) In no event shall the administrative
appeal process result in a determination more adverse to the individual than
was contained in the initial decision being appealed.
(7) The individual and authorized
representative shall be provided with the written administrative appeal
decision, which shall include notice of the right to judicial review, or other
appeal rights, as appropriate. Copies of the decision shall be sent to the
local agency and to the appropriate office.
When the administrative appeal involves one of the medical
determinations listed in paragraph (C)(2) of rule
5101:6-6-01 of the
Administrative Code, a copy of the decision shall also be sent to the medical
determination unit.
When the administrative appeal involves a managed care plan or
"MyCare Ohio" plan, copies of the decision shall also be sent to the managed
care plan or "MyCare Ohio" plan and upon request to the Ohio department of
medicaid.
(J)
Administrative appeal hearing record
The administrative appeal decision, together with all requests,
documents, and correspondence filed in the proceeding, shall constitute the
exclusive administrative appeal hearing record. The record shall be compiled,
certified and maintained by the bureau of state hearings in accordance with
applicable record retention requirements and made available for review by the
individual and authorized representative.
(K) Library of administrative appeal
decisions
The bureau of state hearings shall maintain a library of all
administrative appeal decisions. The decisions shall be available for public
inspection and copying, subject to applicable disclosure safeguards.
(L) Finality
(1) An administrative appeal decision that
affirms or reverses the initial decision being appealed shall constitute the
final and binding administrative decision on the issue(s) involved.
(2) An administrative appeal decision that
vacates the original decision and remands the case to the assigned hearings
section does not constitute a final administrative resolution, since the
supplemental decision issued on remand shall be subject to further
administrative appeal.
(M) Compliance
Compliance with administrative appeal decisions shall be in
accordance with rule
5101:6-7-03 of the
Administrative Code.
