This SHMTL contains two amended rules from Chapter 5101:6-3, one from Chapter 5101:6-4,  three from Chapter 5101:6-5, two from Chapter 5101:6-6, two from Chapter 5101:6-7, one from Chapter 5101:6-8, and one from Chapter 5101:6-9; and two rescinded rules from Chapter 5101:6-2.  The effective date of the rules is January 1, 2018.

SHM 1000:

5101:6-2-35  "State Hearings: Notice of a Managed Care Plan's Denial, Reduction, Suspension, or Termination of a Medical Service."  This rule describes notices issued based on a managed care plan's denial, reduction, suspension, or termination of a medical service.  This rule is rescinded pursuant to federal requirements stating that all adverse benefit determination notices and subsequent grievance or appeal resulting from that notice shall be administered through the managed care plans (MCPs) or MyCare Ohio plans (MCOPs) before accessing the Bureau of State Hearings appeal process.  Adverse benefit determination notice, grievance, and appeal requirements are found in rule 5160-26-08.4 of the Administrative Code for managed care plans and rule 5160-58-08.4 of the Administrative Code for MyCare Ohio plans.

5101:6-2-50  "State Hearings: Notice of Determinations Concerning Spouses Separated by Institutionalization."  This rule describes notices issued based on an agency’s review of eligibility for institutionalized Medicaid.  This rule is rescinded at the request of the Ohio Department of Medicaid, who has taken over responsibility for the now obsolete notices and forms within this rule.

5101:6-3-01  "State Hearings: Grounds for Requesting a State Hearing." This rule describes the process for requesting a state hearing for family services and public assistance programs.  The rule is amended to specify closing fair hearing benefits is not grounds for requesting a state hearing.  Also, language references related to adverse benefit determinations for MCPs or MCOPs is being reorganized to come into compliance with federal requirements stating all adverse benefit determination notices and subsequent grievances or appeals resulting from that notice shall be administered through the managed care plans (MCPs) or MyCare Ohio plans (MCOPs) before accessing the Bureau of State Hearings appeal process.  However, the individual may request a state hearing when the individual disagrees with the MCP or MCOP appeal resolution decision.  For reference, adverse benefit determination notice, grievance, and appeal requirements are found in rule 5160-26-08.4 of the Administrative Code for managed care plans and rule 5160-58-08.4 of the Administrative Code for MyCare Ohio plans. Finally, two grounds for child support services were eliminated, as these grounds are handled administratively through the child support enforcement agency (CSEA), and a clarification was made explaining noncustodial parents can request a state hearing when the CSEA denies a modification request.

5101:6-3-02  "State Hearings: State Hearing Requests."  This rule describes the basic elements of a valid state hearing request and includes deadlines for requesting a state hearing, due process rights, authorization to represent, rights under limited English proficiency and equal employment opportunity (EEO).  The rule is being amended to specify acceptable written authorization legal documents and removes attorney permission to represent an individual without advance proper authorization.  Language is added to clarify written authorization is nontransferable under certain circumstances.  Also, language has been modified in accordance with federal regulations that now require a 120-day state hearing request time limit from the date of an MCP or MCOP adverse benefit determination appeal resolution.  The 90-day requirement is still in effect for all other programs and issues.

5101:6-4-01  "State Hearings: Continuation of Benefits When a State Hearing is Requested."  This rule describes the manner in which continuation of benefits occurs and deadlines associated with receiving continued benefits.  The amended rule removes language references related to adverse benefit determinations for MCPs or MCOPs to come into compliance with federal requirements stating that all adverse benefit determination notices and subsequent grievance or appeal resulting from that notice shall be administered through the managed care plans (MCPs) or MyCare Ohio plans (MCOPs) before accessing the Bureau of State Hearings appeal process.  The rule also offers an individual the opportunity to waive their right to continuation of benefits. For reference, adverse benefit determination notice, grievance, and appeal requirements are found in rule 5160-26-08.4 of the Administrative Code for managed care plans and rule 5160-58-08.4 of the Administrative Code for MyCare Ohio plans.

5101:6-5-01  "State Hearings: Procedures Prior to the State Hearing."  This rule describes the process for submitting state hearing requests to the Bureau of State Hearings (BSH), completing appeal summaries, performing county conferences, and other legal obligations of the parties.  The amended rule clarifies MCPs and MCOPs shall also process state hearing requests within one day and forward them to BSH.  The rule also requires MCPs and MCOPs to notify the Bureau of State Hearings within three calendar days of the state hearing request receive date when the member has not exhausted the grievance and appeal process pursuant to rule 5160-26-08.4 of the Administrative Code for managed care plans and rule 5160-58-08.4 of the Administrative Code for MyCare Ohio plans. References to forms and revision dates were corrected throughout the rule. Language was removed throughout the rule regarding an action or lack of action by a managed care plan to also come into compliance with federal regulations.

5101:6-5-02  "State Hearings: Postponement of the State Hearing."  This rule describes the process for postponing a state hearing.  The rule is amended to add clarifying language that one postponement is permitted for food assistance issues.

5101:6-5-03  "State Hearings: Denial and Dismissal of State Hearing Request."  This rule describes the circumstances under which a state hearing request may be denied or dismissed.  The amended rule states individuals are required to exhaust grievance and appeal remedies through other entities before coming to the Bureau of State Hearings for assistance.  In circumstances where the individual has not utilized the initial grievance and appeal process, a state hearing request may be denied after a state hearing is scheduled, which aligns with federal and state requirements.

5101:6-6-01  "State Hearings: Scheduling and Attendance."  This rule describes the process for scheduling state hearings and outlines who is considered a party to the state hearing.  The amended rule removes all references to action or lack of action and to the Bureau of Managed Care.  Language is also changed to allow the Ohio Department of Medicaid to choose whether to receive notices from the Bureau of State Hearings.

5101:6-6-02  "State Hearings: Rights and Responsibilities of the Participants."  This rule describes the rights and responsibilities of participants to the state hearing.  The amended rule changes the ordering of paragraph (A) to align with Legislative Services Commission (LSC) requirements. Language is added to clarify details around parties declining or not having to take the oath or affirmation.

5101:6-7-01  "State Hearings: State Hearing Decisions."  This rule describes the process for drafting and finalizing a state hearing decision.  The amended rule adds MyCare Ohio to the expedited hearing process, to receiving notification, and to the binding effect of a state hearing decision.  Language is removed regarding action or lack of action by managed care plans.

5101:6-7-03  "State Hearings: Implementation of the Hearing Decision."  This rule describes the process for implementing a state hearing decision and outlines obligations for local agencies with respect to compliance, overpayments, or underpayments.  The amended rule removes references to the Bureau of Managed Care and leaving Ohio Department of Medicaid as the responsible party to assure timely compliance with the state hearing decision. Language is removed requiring the same time line for public assistance and food assistance to come into compliance with instruction from Food and Nutrition Services.

5101:6-8-01  "State Hearings: Administrative Appeal of the State Hearing Decision."  This rule describes the process for requesting an administrative appeal, continuing benefits, and drafting and finalizing the administrative appeal decision.  The amended rule removes references to action or lack of action by a managed care plan, removes references to the Bureau of Managed Care and leaving in Ohio Department of Medicaid.

5101:6-9-01  "State Hearings: Further Appeal Rights."  This rule describes the process for requesting a judicial review after all departmental remedies have been exhausted and includes administrative implementation of the court order.  The amended rule removes references to action or lack of action by a managed care plan, removes references to the Bureau of Managed Care and leaving in Ohio Department of Medicaid.

SHM Instructions:

This information is also available on the Internet and may be accessed at:

ODJFS Electronic Manuals: http://emanuals.jfs.ohio.gov/

InnerWeb Calendar:http://www.odjfs.state.oh.us/lpc/calendar/staff/

Internet Calendar:http://www.odjfs.state.oh.us/lpc/calendar/