If you disagree with a decision made about your services, you can appeal the decision.

The first step in the Medicaid appeals process is asking for a state hearing.

At a state hearing, a hearing officer listens to you or your spokesperson talk about why a decision made about your services might be wrong. They also listen to the agency talk about why a decision was correct.

After the hearing, the hearing officer will send their decision to you in the mail. They could agree with you in full or in part, or the hearing officer could find that the agency’s action is correct.

If you disagree with the outcome of a state hearing, you can request an administrative appeal. If you disagree with the outcome of the administrative appeal, you can request a judicial review.

Your Rights During an Appeals Process

You have the right to

• receive written notice of decisions regarding your Medicaid services,
• a state hearing, if requested within the time limit,
• represent yourself or be represented by a guardian, authorized representative, legal counsel, friend, or other spokesperson,
• request that services continue until a hearing decision, if requested within the time limit,
• receive written notice of the hearing time, date, and place,
• have appeals decided by an impartial hearing officer
• examine the case file and all documents and records to be used by the agency at the hearing,
• bring witnesses to the hearing,
• establish all relevant facts and circumstances,
• present your argument at the hearing,
• receive a written hearing decision,
• access the hearing record,
• receive corrective payments backdated to the date of an incorrect action,
• and seek administrative appeals and judicial review, as available.

State Hearings

You can request a state hearing if

• your application for Medicaid benefits was denied,
• your application for waiver enrollment was denied,
• you get a notice saying that you will be getting fewer services than you did before or that your services are ending,
• you are approved for services, but you disagree with the type or amount of services you were approved for,
• you are denied a place on the waiting list for waiver services,
• or anytime you disagree with an action or decision that is made about your services. 

Getting Help from Your SSA

Your service and support administrator or SSA can help you by

• looking over notices you get about your services and explaining anything you don’t understand,
• explaining program rules that would help you understand why an action was taken and show you how to find those rules,
• helping you submit your request for a hearing,
• letting you know how to get legal help if you want it,
• providing documents that you may need for the hearing, such as assessments or your individual service plan,
• and answering questions you have about the process.

How to Ask for a Hearing

You can fill out the hearing form that came with the notice and mail it back to the Bureau of State Hearings, also called BSH. You can also use the options below to request a hearing.

• BSH must receive your hearing request within 90 days of the mailing date of the notice.

The adult receiving services, an authorized representative, a parent of a minor child, or a legal guardian can all request a hearing.

• Authorized representatives requesting a hearing must include a document signed by the person naming the authorized representative.
  
  
• Legal guardians requesting a hearing must include a copy of the guardianship approval letter from a court.

Request a Hearing

Online at https://secure.jfs.ohio.gov/ols/RequestHearing

By phone when you call the Ohio Department of Job and Family Services Consumer Access Line at
1-866-635-3748 and follow the instructions for State Hearings.

By emailing bsh@jfs.ohio.gov.  Use "State Hearing Request" as the subject line. 

By sending a fax to 1-614-728-9574

Or by mailing your request to

     ODJFS Bureau of State Hearings
     P.O. Box 182825
     Columbus, Ohio 43218-2825

Hearing Notices

After BSH receives the request for a state hearing, they will send you a notice giving the date, time, and place of the hearing. This notice is sent at least ten days before the hearing. The notice will also tell you what to do if you cannot come to the hearing as scheduled.

The lead agency mails all of the documents they plan to present at least three days before the hearing, including an appeal summary, and any exhibits referenced in the appeal summary.

Preparing for a Hearing

Practice what you want to say at the hearing. Be ready to talk about why you think the decision is wrong,

• Do you think the assessment or program application used to make this decision was incorrect?

• Did the assessment or application for services reflect how things really are? 

Be ready to talk about why the service being denied, reduced, or terminated is needed, or why the services approved are not enough to meet your needs.

Get together any documents that you think show that the agency’s decision is not correct. That might be things like

• an assessment,
• your individual service plan,
• physician’s orders,
• therapy reports, 
• letters from medical professionals, or
• hospital records.

Bring these documents with you to the hearing. They will become part of an official record of the hearing. It is a good idea to make some notes for yourself so that you remember everything you want to say.

It is important to continue to work with your SSA to plan for services, in case the hearing decision is not in your favor.

What to Expect During a Hearing

Hearings are usually held at local county departments of job and family services, or JFS. They are usually one hour long. A hearing officer from the Ohio Department of Job and Family Services and other state officials usually can not attend in-person so they usually attend the hearing by phone. 

You can go to the hearing by yourself or you can bring witnesses, friends, family, or an attorney to help present your case. Your SSA may attend to help you share information or provide facts to the hearing officer. 

Since county boards of developmental disabilities are local Medicaid authorities, their employees and contractors may not attend the hearing to

• oppose or disagree with an action taken by a state agency,
• offer opinions or interpretations about how rules should be applied,
• serve as the person’s advocate,
• or argue a position on the person’s behalf.

The hearing officer will swear in anyone who plans to speak during the hearing. 

A representative from the agency will explain the reasons for the action, and then you will be able to talk about why you think the action is incorrect. 

You will also be able to share the documents that you gathered that support what you are saying. 

The hearing officer may ask you questions. You can write down notes during the hearing so that you remember everything you want to say. You will be able to ask the agency representative questions and they will be able to ask you questions.

Hearing Decision

You will receive a written decision within 90 days of your original request for a hearing. The decision will be one of the following. 

• Sustained: Meaning the hearing officer found the agency’s action was incorrect, either in full or in part.
• Sustained with compliance: Meaning the agency has been ordered to do something.
• Overruled: Meaning the hearing officer found that the agency’s action was correct.

Actions ordered by the hearing officer, such as completing a new assessment, are required to happen within 15 days of the hearing decision.

If the hearing officer agrees with the agency, the proposed reduction or termination of services may take effect on the date the decision is issued. If you disagree with the decision from the hearing, you can choose to request an administrative appeal.  

Administrative Appeals

You can send a requests for an administrative appeal in writing to the BSH at the same address, within 15 calendar days of the date the hearing decision was issued.

The adult receiving services, the authorized representative, the legal guardian, or the parent of a minor child can submit requests.

An administrative appeal examiner will review the hearing record and recording to determine if the hearing officer’s decision was correct, based on laws and rules.

You may request that services continue while you are waiting for a decision when you submit your request for an administrative appeal. Services will not continue automatically when you request an administrative appeal. 

Administrative Appeal Decisions 

• Affirmed: Meaning that the administrative appeal examiner agrees that the hearing decision contained no errors and the hearing officer’s decision stands.
• Reversed: Meaning that the examiner indicates that the hearing decision included errors that resulted in a negative outcome for the person. Compliance is ordered and must be completed within 15 days.
• Vacated or remanded: Meaning the examiner indicates that the record is not sufficient for the appeal to be decided.
• Or another hearing or decision may be ordered.

Judicial Review

Someone who is not an attorney, including a guardian or authorized representative, may not be allowed by the court to represent the person requesting or receiving services in court. (Check with your local court.)

There is no automatic “stay” or continuation of services when requesting a judicial review.  

A motion must be filed with the court to request a stay.

Remember that all decisions at a state hearing, administrative appeal, or judicial review are all time-limited. Decisions remain in effect for the rest of the waiver span or until a new assessment is completed. Assessments are reviewed and updated at least once every year as part of the annual planning process.  Assessments may also be completed or updated whenever a person’s needs change.