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What is a Medicaid appeal?

When an agency or managed care plan makes a decision about your Medicaid services that you disagree with, you generally have the right to appeal the decision. An appeal is saying that you disagree with the decision and want someone with more authority to review it.

How do I appeal?

It depends on whether your disagreement is with a managed care plan or another agency that is not a managed care plan:

  • If a managed care plan made the decision about your services, you generally have to appeal through your managed care plan before you can appeal using the state hearing process. There are some exceptions to this, which are explained below.
  • If another agency that is not a managed care plan (like the Ohio Department of Medicaid, Ohio Department of Developmental Disabilities or a waiver case management agency) made the decision, you must appeal using the state hearing process.

See also DRO’s Medicaid Appeals Flowchart (coming soon).

MANAGED CARE PLAN APPEALS

How do I appeal a decision made by a managed care plan?

When a managed care plan makes an “adverse benefit determination” (for example, denying or reducing your services), the managed care plan must tell you in writing and tell you how to appeal. Look in your member handbook to find more information. You also have the right to ask for an “expedited appeal,” and to ask your managed care plan for help in filing an appeal. Some people in Ohio are in a special managed care program called MyCare Ohio. This factsheet does not discuss MyCare Ohio plans. You can find more information about managed care plan appeals in Ohio Admin. Code 5160-26-08.4.

Are there deadlines for filing an appeal with my managed care plan?

Yes. Look for a date on the notice you got in the mail. You must file an appeal within 60 days from the mailing date on your notice. However, there is a shorter deadline you need to follow if your services are being reduced and you want those services to continue at the current level during your appeal. This is called “continuation of benefits” or “continuing assistance.” In order to receive continuation of benefits, you must appeal within 15 days from the mailing date on your notice. You also have to file the appeal before your current “authorization period” has expired (for example, the period of time your managed care plan approved nursing services). If you do this, your services must be kept at their current level until the managed care plan makes a decision (called an “appeal resolution”).

What are my rights if I do not receive written notice in the mail?

If you do not receive written notice (for example, if someone tells you over the phone your services will be reduced), you can still file an appeal with the managed care plan. You could handle this in one of several ways. You could file an appeal, you could ask the managed care plan to put the decision in writing before you appeal, or you could send the managed care plan a letter documenting what you were told and when and then file an appeal. In fact, if you do not receive written notice, this may allow you to skip the managed care plan appeal process and go straight to the state hearing process instead. If you have questions about what you should do, you can call Disability Rights Ohio for help.

If your Medicaid services were actually reduced or stopped but you never got a written notice, you can appeal and ask your managed care plan and/or the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings to “reinstate” (or put back) your services.

How long will it take the managed care plan to make a decision about my appeal?

The managed care plan must make a decision about your appeal (called an “appeal resolution”) within 15 days from your request and send you a copy in writing, though the timeframe can be longer in some situations. You have the right to request a faster appeal, called an “expedited appeal,” if your physical or mental health or ability to function would be seriously put at risk within this timeframe. If your request for an expedited appeal is approved, the managed care plan must decide what to do about your appeal within 72 hours from your request, though this timeframe can sometimes be longer as well.

What are my rights if I disagree with the appeal resolution?

If you disagree with the appeal resolution (or do not receive the appeal resolution in writing in the timeframe allowed), you can request a state hearing from the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings. If you receive a state hearing request form, you can fill out that form and send it to the Bureau of State Hearings. But you do not have to use that form.

To ask for a state hearing, call or write to the Bureau of State Hearings:

  • Mail: ODJFS Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825
  • Fax: 614-728-9574
  • Email: bsh@jfs.ohio.gov, and put “State Hearing Request” in the subject line
  • Online: secure.jfs.ohio.gov/ols/RequestHearing
  • Phone: 866-635-3748, choose option number one from the automated voice menu

Note that if someone is requesting a state hearing for you, he or she may need to include a “written authorization.” For more information, see the question below: “Can someone else request a state hearing for me?”

Are there deadlines for asking for a state hearing?

Yes. Look for a date on your appeal resolution. The ODJFS Bureau of State Hearings must receive your state hearing request within 120 days from the date the appeal resolution was mailed. However, there is a shorter deadline you need to follow if you have been receiving “continuation of benefits” and want them to stay in place until a state hearing decision is made. In order to receive “continuation of benefits,” the ODJFS Bureau of State Hearings must receive your state hearing request within 15 days from the date the appeal resolution was mailed. (If you miss this deadline but your request is received within 10 days of your change in services, ODJFS can reinstate your services if it finds “good cause” for the delay in making the request).

OTHER MEDICAID APPEALS

How do I appeal a decision made by an agency that is not a managed care plan?

When an agency that is not a managed care plan (like the Ohio Department of Medicaid, Ohio Department of Developmental Disabilities or a waiver case management agency) makes a decision to deny or reduce services, it must tell you in writing and tell you how to appeal by asking for a state hearing from the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings. If you receive a state hearing request form, you can fill out that form and send it to the Bureau of State Hearings. But you do not have to use that form.

To ask for a state hearing, call or write to the Bureau of State Hearings:

  • Mail: ODJFS Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825
  • Fax: 614-728-9574
  • Email: bsh@jfs.ohio.gov, and put “State Hearing Request” in the subject line
  • Online: secure.jfs.ohio.gov/ols/RequestHearing
  • Phone: 866-635-3748, choose option number one from the automated voice menu

 Note that if someone is requesting a state hearing for you, he or she may need to include a “written authorization.” For more information, see the question below: “Can someone else request a state hearing for me?”

Are there deadlines for asking for a state hearing?

Yes. Look for a date on the notice you got in the mail. The ODJFS Bureau of State Hearings must receive your state hearing request within 90 days from the mailing date on your notice.

However, there is a shorter deadline you need to follow if your services are being reduced and you want those services to continue at the current level until a decision is made. This is called “continuation of benefits” or “continuing assistance.” In order to receive continuation of benefits, the ODJFS Bureau of State Hearings must receive your state hearing request within 15 days from the mailing date on your notice. (If you miss this deadline but your request is received within 10 days of your change in services, ODJFS can reinstate your services if it finds “good cause” for the delay in making the request).

What are my rights if I do not receive written notice in the mail?

If you do not receive written notice (for example, if someone tells you over the phone your services will be reduced), you can still request a state hearing. You could handle this in one of several ways. You could request a state hearing, you could ask the agency to put the decision in writing before you request a state hearing, or you could send the agency a letter documenting what you were told and when and then request a state hearing. 

If your Medicaid services were actually reduced or stopped but you never got a written notice, you can request a state hearing and ask the ODJFS Bureau of State Hearings to “reinstate” (or put back) your services. You should also ask your agency case worker to reinstate your services.

OTHER INFORMATION REGARDING STATE HEARINGS

Can someone request a state hearing for me?

Yes, but they generally have to include some additional paperwork called a “written authorization” to show that they are your authorized representative. (There are some exceptions to this requirement if the person is the parent or legal guardian of a minor, your spouse, or certain emergency situations that prevent you from giving written consent). The written authorization could be the letters of guardianship for guardians. For powers of attorney, it could be the power of attorney document. For others, it could be a statement, signed by you, telling the Bureau of State Hearings that the other person is your authorized representative. You can use this form to designate someone as your authorized representative.

How long will it take the state hearing officer to make a decision?

After your state hearing, you should receive a hearing decision in the mail. Under Ohio law, state hearing decisions must be mailed within 70 days from date of the state hearing request (unless the ODJFS Bureau of State Hearings agreed to “expedite” your decision).
If the hearing officer agrees with you and finds that the agency acted incorrectly, the hearing decision will “sustain” your appeal. If the hearing officer disagrees with you and finds that the agency’s action was correct, the decision will “overrule” your appeal.

What are my rights if I disagree with the state hearing decision?

If you disagree with the state hearing decision, you have the right to file an administrative appeal. There are important timeframes you must follow. For more information, see DRO’s publication on administrative appeals.

What should I do if I have questions?

If you have questions throughout your appeals process, call Disability Rights Ohio at 800-282-9181 and select option 2 for intake.

Reviewed December 2018

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