Opening a letter from the Ohio Department of Medicaid (ODM) to find the word “DENIED” or “TERMINATED” can feel like a punch to the gut. If you are seeking coverage for a parent’s nursing home care or trying to secure home-based waivers, a denial often triggers immediate panic regarding financial security and quality of life.
However, a denial notice is not the final word. It is simply the opening move in a bureaucratic process that you have the right to challenge.
According to Health Affairs, nearly 17% of Medicaid claims are initially denied, often due to procedural errors, missing documentation, or automated system flags like the Electronic Visit Verification (EVV) requirements.
In Ohio, the appeals process, officially known as a State Fair Hearing, is your statutory right to have an impartial third party review the facts of your case.
At Brumbaugh Law, we move beyond the dense legal jargon of the Ohio Administrative Code to provide you with a clear, actionable plan to protect your assets and your health.
Understanding the 15-Day Safety Net
Most people assume they have plenty of time to figure out their next step after a denial. While it is true that you generally have 90 days from the mailing date of the notice to request a hearing, waiting that long can be a costly mistake.
The 15-Day Rule (Continuance of Benefits)
Under Ohio Administrative Code, if you are currently receiving benefits and you request a state hearing within 15 days of the notice date (or before the effective date of the action), your benefits cannot be reduced or terminated until the hearing decision is made.
This “maintenance of effort” provision is vital. It makes sure that nursing home payments or waiver services continue uninterrupted while you fight the decision. If you miss this 15-day window, you can still appeal up to the 90-day mark, but your benefits may stop in the meantime, leaving you liable for costs during the gap.
Why Do Denials Happen
To win an appeal, you must first understand the enemy. The “Notice of Action” you received cites specific codes, but the real reasons usually fall into three categories:
- Financial Eligibility: The state believes your assets or income exceed the limit. This often happens when families attempt “do-it-yourself” asset protection without an estate planning attorney to structure trusts or gifts correctly.
- Medical Necessity: Roughly 51% of health insurance denials stem from a determination that the level of care isn’t “medically necessary.” For seniors, this might mean the state believes a parent needs assisted living rather than skilled nursing.
- Documentation & Procedural Errors: Missing bank statements, failure to verify citizenship, or discrepancies in the EVV system can trigger an automatic denial. These are often the easiest to fix but the most frustrating to encounter.
How to Officially Request a State Fair Hearing
You do not need to write a legal brief to start the appeal process. You simply need to notify the Bureau of State Hearings that you disagree with the decision. Ohio offers several ways to do this:
- Online (Fastest): Use the SHARE Portal (State Hearing Access to Records Electronically) at hearings.jfs.ohio.gov. This allows you to upload documents and track your status.
- Email: Send your request to bsh@jfs.ohio.gov.
- Phone: Call the ODJFS Consumer Access Line at 866-635-3748.
- Mail/Fax: Fill out the form attached to your denial notice and send it to the Bureau of State Hearings in Columbus.
Always keep proof of your request. If you fax it, keep the transmission receipt. If you mail it, use certified mail. If you use the portal, take a screenshot of the confirmation.
Gathering Evidence For Your Winning Case
Once the hearing is scheduled, the burden of proof shifts. You cannot rely on the hearing officer to find errors on their own; you must prove the agency was wrong.
This stage requires organization. You are essentially building a dossier to present to the Administrative Law Judge (ALJ). The specific evidence depends on the reason for denial, but a robust case file often includes medical reports, receipts, and tax documents.
The “County Appeal Summary”
Before the hearing, the agency (usually your local Job and Family Services) must send you an “Appeal Summary.”
This document explains exactly why they denied you and what rules they followed. Read this carefully. If they claim you didn’t provide a specific bank statement, your defense is simply to provide that statement.
What to Expect at the Fair Hearing
The term “hearing” intimidates many people, but a Medicaid Fair Hearing is not a criminal trial. There is no jury, and it typically does not take place in a courtroom.
- Who is there? The Hearing Officer (an attorney employed by the state to be neutral), a representative from the agency that denied you, and you (plus your attorney or authorized representative).
- The Format: The agency explains their action first. Then, you present your side. You can bring witnesses, submit documents, and ask the agency representative questions.
- The Atmosphere: While formal, it is designed to be accessible to the public. However, the rules of evidence still apply, and emotional pleas carry less weight than documented facts.
Do You Need an Elder Law Attorney?
Technically, you can represent yourself (“pro se”) or have a friend or social worker speak for you. However, Medicaid law is notoriously complicated, and often compared to the Tax Code in its density.
If the denial is a simple clerical error (e.g., a missing signature), you may be able to resolve it with a phone call or a “County Conference” before the formal hearing.
However, if the denial involves asset transfer penalties (look-back period issues), trust interpretation, or medical necessity for long-term care, the financial stakes are often too high to risk a DIY approach. A rejected appeal can result in months of uncovered nursing home bills, potentially costing a family tens of thousands of dollars.
The Decision Timeline After The Hearing
The Hearing Officer does not make a decision on the spot. They will review the evidence and issue a written decision.
- Timeline: The state is required to issue a decision within 90 days of your initial request (or 3 working days if the hearing was expedited due to immediate health risks).
- Sustained: You won. The agency must take corrective action immediately.
- Overruled: The denial stands.
- Next Levels of Appeal: If you lose the fair hearing, the road doesn’t necessarily end. You can request an Administrative Appeal within 15 days of the decision. If that fails, you have the right to appeal to the Court of Common Pleas in your county.
Frequently Asked Questions
Q: Can I reapply for Medicaid while my appeal is pending?
A: Generally, you are appealing a specific decision. However, if your circumstances change (e.g., your assets drop below the limit), you can file a new application. It is vital to coordinate this strategy to avoid confusing the system.
Q: Does it cost money to request a hearing?
A: No, there is no filing fee for a Medicaid State Fair Hearing.
Q: What if I miss the 90-day deadline?
A: The deadline is strict. However, if you have “good cause” (like a hospitalization or a natural disaster that prevented you from filing), the state may grant an exception, but this is rare and difficult to prove.
Moving Forward with Confidence
A Medicaid denial is a hurdle, not a dead end. By understanding the timeline, gathering the right evidence, and knowing when to seek professional counsel, you can handle this process effectively.
At Brumbaugh Law Firm, we believe that legal and financial planning should empower seniors, not confuse them. If you are correcting a documentation error or fighting for the long-term care coverage your loved one deserves, you have options.
Schedule a consultation today!
