Download the PDF version of this page: Frequently Asked Questions about Medicaid: Service Denials and Reductions
Many people with disabilities in Ohio are enrolled on a Medicaid home and community-based services waiver (for example, the Individual Options waiver or the Ohio Home Care waiver), programs that allow them to receive the services they need in a community setting rather than in an institution. Also, people with disabilities often receive home health aide or nursing services through the state Medicaid plan.
If you receive these types of Medicaid services and find out that they will be reduced or stopped, or if you need new or additional services but your request has been denied, there are several important things that you should know to protect your rights and to make sure you receive the services you need.
Contents
- Do I have to receive something in writing before my Medicaid services are reduced or stopped?
- What should I do if I receive a notice that my Medicaid services will be reduced or stopped?
- What happens if I request a state hearing after the 15-day time period has expired?
- At the state hearing, how can I show that I still need the same level of services I had been receiving?
- What do I do if I made a request for new or additional services and it was denied?
- At the state hearing, how can I show that I need the new or additional level of services I requested?
Do I have to receive something in writing before my Medicaid services are reduced or stopped?
Yes. You must be given notice in writing before your Medicaid services can be reduced or stopped, and it must be mailed to you or delivered to you in person at least 15 days in advance. The notice must tell you why your Medicaid services will be reduced or stopped and also explain your right to request a state hearing if you disagree.
If your Medicaid services were reduced or stopped, but written notice was never provided to you (for example, if someone merely told you by telephone), then your services must be restored. If this happens, it is a good idea to request a state hearing immediately and also call the Bureau of State Hearings and your case worker to ask that your services be restored.
What should I do if I receive a notice that my Medicaid services will be reduced or stopped?
Although you have 90 days to request a state hearing, it is extremely important that you request a state hearing within 15 days of the date the written notice was mailed to you. If you do this, then your Medicaid services cannot be reduced or stopped unless both a state hearing is held and the state hearing decision rules against you (this is called a “stay-put”).
What happens if I request a state hearing after the 15-day time period has expired?
If you request a state hearing after the 15-day time period, then you will not receive a “stay-put” and your Medicaid services will be reduced or stopped, unless a state hearing decision or administrative appeal decision later rules in your favor. However, if you request a state hearing within 10 calendar days after the 15-day time period has ended, and you can give a good reason for the delay (for example, an injury or illness experienced by you or your family or a death in the family), then you will receive a “stay-put” until a state hearing decision is announced.
At the state hearing, how can I show that I still need the same level of services I had been receiving?
When you request a state hearing because you received notice that your Medicaid services will be reduced or ended, then the state of Ohio (or maybe your county, depending on the case) must show at the state hearing that its proposal to reduce or end your Medicaid services is correct. But you should definitely be prepared to explain why you still need the same level of services.
Medicaid services must be “medically necessary,” so you should ask your doctor to provide you a letter explaining why you still need the same level of services. Also, you (or your guardian, a family member, or your advocate who knows a lot about your needs) can explain at the hearing why you still need the same level of services.
There may be a proposal to reduce or end your Medicaid services, even though your needs or condition have not changed at all. This is often done as a way to save the state of Ohio money, which is not a good reason to reduce or end your services. If this happens to you, you should argue at the state hearing that your services should not be reduced or stopped if your needs or condition have not changed.
Finally, if the proposal to reduce or end your Medicaid services means that you may have to move to an institution, you should definitely explain this at the state hearing. You have a right under federal law to receive services in the community instead of an institution.
What do I do if I made a request for new or additional services and it was denied?
If your needs have increased, your condition has gotten worse, or your parent or other caretaker is no longer able to care for you to the same extent as before, and your request for new or additional services was denied, you should immediately request a state hearing. The state of Ohio (or maybe your county, depending on the case) must give you notice in writing describing why you were denied new or additional services and also explaining your right to request a state hearing. However, this does not always happen, but you can still request a state hearing, even without this written notice. Also, you may have made a request for new or additional services but never received a response to your request. In this case, you should assume your request has been denied.
You have 90 days to request a state hearing, but unfortunately there is no benefit of a “stay-put” in these cases, so you should make the state hearing request as soon as possible.
At the state hearing, how can I show that I need the new or additional level of services I requested?
The state of Ohio (or county) must prove at the state hearing that its decision to deny your request for new or additional services was correct. But you should also definitely be prepared to show that you need these new or additional services. It is important to explain at the state hearing that your condition has gotten worse, your needs have increased, or that a parent or other caretaker can no longer care for you to the same extent (or any other reason why you need new or additional services).
Medicaid services must be “medically necessary,” so you should ask your doctor or other health care professionals to provide you a letter explaining why you need new or additional services. Also, you (or your guardian, a family member, or your advocate who knows a lot about your needs) can explain at the hearing why you need more services.