5101:6-4-01. State hearings: continuation of benefits when a state hearing is requested

(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(2) The appeal is withdrawn or abandoned pursuant to rule 5101:6-5-03 of the Administrative Code.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 food assistance or basis of issuance occurs while the hearing decision is pending.

(5) The assistance group specifically waives continuation of food assistance 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 food assistance certification period expires. Further entitlement to food assistance 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 food assistance 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 in the food assistance program), 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) Food assistance 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 food assistance 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, food assistance 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 food assistance 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 work day 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 work day 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 food assistance 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.

Effective: 1/1/2018
Five Year Review (FYR) Dates: 10/17/2017 and 01/01/2023
Promulgated Under: 119.03
Statutory Authority: 5101.35
Rule Amplifies: 5101.35 , 5167.26, 5164.758, 5160.011
Prior Effective Dates: 04/15/1975, 06/02/1980, 05/01/1982, 10/01/1982, 01/01/1983, 04/01/1983, 12/01/1983, 10/03/1984 (Emer.), 12/22/1984, 04/01/1987, 04/01/1989, 11/01/1990, 10/01/1991, 02/01/1992, 06/01/1993, 03/01/1994 (Emer.), 05/15/1994, 02/01/1995, 12/01/1995 (Emer.), 02/19/1996, 06/01/1997, 10/01/1997 (Emer.), 12/30/1997, 05/15/1999, 06/01/2003, 09/01/2008, 07/01/2009, 08/01/2010, 07/01/2011 (Emer.), 01/01/2012, 02/28/2014