(A)       The right to a state hearing is limited to actions by the Ohio department of job and family services (ODJFS), the Ohio department of medicaid (ODM), the local agency, or an agent of ODJFS, ODM, or the local agency. A hearing need not be granted when a change in state or federal law, or local agency policy adopted pursuant to options authorized in state law, requires automatic adjustments of benefits for classes of recipients. If the reason for the request is the misapplication of the change to the appellant's individual circumstances, hearing rights exist. The closure of fair hearing benefits is not grounds for requesting a state hearing nor subject to notice rights.

(B)       The grounds for requesting a state hearing in regard to family services program benefits are as follows:

(1)       An application for benefits has been denied, acted upon erroneously, or not acted upon with reasonable promptness.

(2)       The agency has proposed or acted to reduce, suspend, terminate, or withhold benefits, or the assistance group believes that the level of benefits is not correct.

(3)       A request for an adjustment in benefits has been denied, not acted upon, acted upon erroneously, or not acted upon with reasonable promptness.

(4)       The agency has determined that an overpayment or overissuance has occurred, or the assistance group believes that the amount of the overpayment or overissuance is not correct.

(5)       The individual disagrees with any decision, action, or lack of action involving work registration exemption status or requirements, or work activity exemption status or participation.

A regular employee believes that the assignment of an Ohio works first (OWF) work activity participant violates the prohibition against displacement.

(6)       A request for prior authorization of a medical service or additional therapeutic leave days has been denied, or the individual believes that the reviewing agency's decision on a request for pre-certification of a hospital admission or medical procedure is not correct.

(7)       The individual or provider of long-term care believes that the level of care assigned, or the effective date of the level of care assigned, to the individual is not correct.

(8)       The individual disagrees with a preadmission screening or resident review determination made by the Ohio department of mental health and addiction services or the Ohio department of developmental disabilities.

(9)       The enrollment or decision to continue enrollment of the individual in the coordinated services program (CSP), or denial of the individual's request to change a CSP-designated provider.

(10)     In regard to actions involving a medicaid managed care plan (MCP) or "MyCare Ohio" plan (MCOP):

(a)       The individual disagrees with one of the following actions taken by a medicaid managed care plan:

(i)         An MCP or MCOP appeal resolution decision based on an adverse benefit determination, as described in rules 5160-26-08.4 or 5160-58-08.4 of the Administrative Code, as applicable.

(i)         The denial or limited authorization of a requested service, including the type or level of services.

(ii)        The reduction, suspension, or termination of services prior to the individual receiving the services previously authorized by the plan.

(iii)       The failure to act on a request for services within the timeframe set forth in rule 5160-26-03.1 of the Administrative Code.

(iv)(ii)  A managed care plan's enrollment or decision to continue enrollment of the individual in the coordinated services program (CSP), or denial of the individual's request to change a CSP-designated provider.

(v)(iii)  The plan's upholding the denial of payment for a medical service for which the individual is being billed.

(b)       The right to a state hearing applies only to action or lack of action by the managed care plan. If the action or lack of action with which the individual disagrees is by the individual's physician or another sub-contracting provider, the individual may instead pursue the issue through the managed care plan's grievance process.

(c)(b)   The individual disagrees with a decision of ODM that the individual does not meet an exclusion from mandatory managed care plan membership, or a decision to deny the individual's request for just cause termination of membership in an assigned managed care plan and enrollment in a different managed care plan.

(c)        The MCP or MCOP fails to adhere to the notice and timing requirements for appeals set forth in rule 5160-26-08.4 or 5160-58-08.4 of the Administrative Code.

(11)     The agency has denied payment for a medical service provided to an individual enrolled in the coordinated services program (CSP) by a nondesignated provider.

(12)     The individual disagrees with any decision, action, or lack of action involving assistance under the supplemental security income (SSI) case management program.

(13)     The individual feels that a county board that has medicaid local administrative authority under division (A) of section 5126.055 of the Revised Code for home and community-based services violated the right of an individual to choose a provider that is qualified and willing to provide services to the individual.

(14)     In the medicaid program, either the institutionalized spouse or the community spouse may request a hearing concerning the following determinations:

(a)       Community spouse monthly income allowance.

(b)       Community spouse's minimum monthly maintenance needs allowance.

(c)        Family allowance.

(d)       Community spouse and institutionalized spouse total gross income.

(e)       Spousal share of assessed resources.

(f)        Current countable resources.

(g)       Community spouse resource allowance.

(C)       The grounds for requesting a state hearing in the child support (Title IV-D of the Social Security Act (as in effect on February 28, 2014)) program, by an applicant, recipient, or custodial parent are as follows:

(1)       An application for child support services has been denied, acted upon erroneously, or not acted upon with reasonable promptness.

(2)       A recipient of child support services, believes the case has been acted upon erroneously, or not acted upon with reasonable promptness.

(3)(2)   The recipient believes that the child support enforcement agency (CSEA) has failed to use appropriate establishment or enforcement techniques.

(4)(3)   The custodial parent believes that child support collections have not been distributed or disbursed correctly or questions the accuracy of the arrears owed to ODJFS at termination of cash benefits.

(5)(4)   The custodial parent believes that child support payments, including payments owed to the custodial parent due to agency error, are not being issued with reasonable promptness.

(6)(5)   The custodial parent believes that the CSEA has failed to take action against an employer for failure to promptly forward payments withheld from the absent parent's wages.

(7)       The custodial parent disagrees with the results of an investigation concerning termination of a support order.

(8)(6)   The custodial parent disagrees with the CSEA's decision to close the child support case.

(7)       The custodial parent disagrees with the CSEA's decision to deny a modification request.

(D)       The grounds for requesting a state hearing in the child support program by the noncustodial parent are as follows:

(1)       Services for establishing paternity have been denied.

(2)       The CSEA has refused to review the noncustodial parent's support order for modification.

(3)       The noncustodial parent disagrees with the CSEA's decision to deny a modification request results of an investigation concerning termination of a support order.

Effective: 1/1/2018

Five Year Review (FYR) Dates: 10/17/2017 and 01/01/2023

Certification: CERTIFIED ELECTRONICALLY

Date: 12/22/2017

Promulgated Under: 119.03

Statutory Authority: 3125.25, 5101.35

Rule Amplifies: 3125.25, 5101.35, 5126.055, 5160.011, 5164.758, 5167.13

Prior Effective Dates: 06/28/1976, 09/01/1976, 10/01/1978, 12/01/1979, 06/01/1980, 06/02/1980, 09/19/1980, 10/01/1981, 02/01/1982, 04/01/1982, 05/01/1982, 10/01/1982, 01/01/1983, 01/17/1983, 04/01/1983, 07/01/1983, 11/01/1983 (Temp.), 12/01/1983, 03/01/1984 (Temp.), 06/01/1984, 05/01/1985 (Emer.), 07/01/1985 (Emer.), 07/30/1985, 09/29/1985, 04/01/1986, 04/01/1987, 04/01/1989, 12/01/1989 (Emer.), 03/22/1990, 10/01/1990, 10/01/1991, 06/01/1993, 02/01/1995, 06/01/1997, 10/01/1997 (Emer.), 12/30/1997, 05/15/1999, 06/01/2003, 05/31/2004, 09/01/2008, 08/01/2010, 07/01/2011 (Emer.), 01/01/2012, 02/28/2014