Ohio Medicaid Appeals and Fair Hearings: How to Appeal

If your Ohio Medicaid was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits at the prior level while the appeal is pending.1,2

In This Guide

• What an Ohio Medicaid appeal covers
• The Ohio Medicaid appeal deadlines that decide your case
• How to keep your benefits during the appeal
• Managed care (MCO) appeals: exhaust your plan first
• How to request a fair hearing in Ohio
• Frequently asked questions

What an Ohio Medicaid appeal covers

Federal Medicaid law guarantees every applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires Ohio's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted on promptly, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.1

In practice, that right lets you appeal:

• An application denial based on income, assets, household size, or documentation
• A termination or reduction of your eligibility
• A reduction in service hours, such as fewer personal care or home care hours
• A denial, suspension, or termination of a covered service by your managed care plan
• A prior authorization denial or a level-of-care determination

Ohio decides these appeals through the ODJFS Bureau of State Hearings.2 The steps you follow depend on who took the action: the Ohio Department of Medicaid and its county agencies handle eligibility and fee-for-service decisions, while a managed care plan handles service denials for its own members, which run through the plan's internal appeal first.

The Ohio Medicaid appeal deadlines that decide your case

Three deadlines can apply to an Ohio Medicaid appeal, and they are not the same length. One decides whether your appeal is heard, one decides whether your benefits keep running, and a third applies when the denial came from a managed care plan.

For an eligibility or fee-for-service action, federal law under 42 CFR 431.221(d) requires the state to allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a hearing.3 In Ohio, ODJFS must receive your state-hearing request within 90 days of the mailing date on the notice.2 The deadline runs from the mailing date printed on the notice, not the day it reached your mailbox.

A second, shorter deadline governs whether your benefits continue. To keep receiving your benefits at the prior level while the appeal is decided, you must request the hearing within 15 days of the notice.2 Miss the 15 days and you can still appeal within the 90-day window, but your services may stop or drop in the meantime.

A managed care denial follows a different track. If your denial came from a managed care plan, you have 60 calendar days from the date on the plan's notice of action to file the plan's internal appeal.2,5 After the plan resolves that appeal against you, you have 90 calendar days from the date of the adverse appeal resolution to request a state hearing.2 Federal law sets that post-resolution window at no fewer than 90 and no more than 120 days, and Ohio uses 90.7

How to keep your benefits during the appeal

Keeping your benefits during an appeal is called aid paid pending, or continuing assistance. It lets your coverage run at the prior level while your case is decided, and it turns on a short deadline.

To keep your assistance or services at the prior level while the appeal is pending, request the hearing within 15 days of your notice.2 In managed care, the same 15-day clock applies to the internal appeal you file with your plan.2

This carries out a federal protection. Under 42 CFR 431.230(a), when the agency sends the required advance notice and you request a hearing before the date of action, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless the only issue is one of federal or state law or policy.4 Ohio's 15-day instruction is how the state carries out that rule. Note that the federal trigger is the date of action, not the 15 days: if the effective date printed on your notice falls sooner than 15 days out, request the hearing before that date.4

Continued benefits carry one risk. If your assistance keeps running during the appeal and the hearing decision goes against you, you may have to repay the benefits you were not eligible to receive.2 What can be recovered is bounded: 42 CFR 431.230(b) permits the agency to recoup the cost of services furnished solely by reason of the continuation, not everything you received while the appeal was pending.4 Weigh that against the cost of going without coverage while you wait for a decision.

Continuation is not automatic. When an adverse-action notice arrives, find the date on it, request the hearing within 15 days, and ask in writing to keep your benefits.

Managed care (MCO) appeals: exhaust your plan first

Ohio runs its general Medicaid population through the Ohio Department of Medicaid Next Generation managed care program, under which the state contracts with seven managed care organizations (MCOs): AmeriHealth Caritas Ohio, Anthem Blue Cross and Blue Shield, Buckeye Community Health Plan, CareSource Ohio, Humana Healthy Horizons in Ohio, Molina Healthcare of Ohio, and UnitedHealthcare Community Plan of Ohio. A single statewide pharmacy benefit manager (SPBM) handles the pharmacy benefit.2 When a plan denies care, you appeal to the plan before you can reach a state hearing.

You, your authorized representative, or your provider may file an appeal with the MCO or SPBM, orally or in writing, within 60 calendar days from the date the plan's notice of action (NOA) was issued.2,5 A Medicaid plan has only one level of internal appeal.5

Under 42 CFR 438.408(b), the state must set the plan's resolution deadlines at no longer than 30 calendar days for a standard appeal and no longer than 72 hours for an expedited one, counted from the day the plan receives the appeal. Either deadline can be extended by up to 14 calendar days if you ask for the extension, or if the plan shows the state agency that more information is needed and the delay is in your interest.7 The plan's written notice of an adverse benefit determination must explain how to appeal, how to request an expedited appeal, and how to ask that your benefits continue.8

Once you exhaust the MCO or SPBM appeal process, you have the right to request a state hearing.2 After an adverse plan appeal resolution, request the state hearing within 90 calendar days of that resolution by contacting the ODJFS Bureau of State Hearings or your local county department of job and family services (CDJFS).2

How to request a fair hearing in Ohio

You request a state hearing from the ODJFS Bureau of State Hearings. There are four ways to file.2

Whichever method you use, act within the deadline that governs your case: 90 days of the mailing date for an agency action, 90 days of the plan's adverse resolution for a managed care denial, and within 15 days if you want your benefits to continue while the appeal is pending.2 If the action takes effect sooner than that, file before its effective date.4

Learn More

Find personalized help navigating an Ohio Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.