(a) Children's Special Health Care Needs Program. Circumstances which constitute a basis for a hearing are:
- (1) the individual's application for services is denied;
- (2) a decision regarding eligibility has not been reached within 45 days from the date of application;
- (3) the client disagrees with the date on which assistance begins; or
- (4) the client is dissatisfied with an action affecting eligibility for receipt of medical services or with the relevant policy as applied to his or her situation.
(b) Child care services. A hearing may be granted if:
- (1) there is a delay in reaching a decision on an application for assistance of more than 30 days;
- (2) the client disagrees with the date on which assistance begins; or
- (3) the client disagrees with the amount of the family share co-payment.
(c) Services for persons with developmental disabilities.
- (1) A hearing may be granted if:
- (A) the application for services is denied;
- (B) the Department of Human Services (DHS) action regarding the application for state-funded services has not occurred within 180 days from the date DHS received the application and the client has exhausted the remedies afforded by the Office of Client Advocacy (OCA);
- (C) when resources are sufficient for initiation of Home and Community Based Waivered Services and action is not taken within 45 days; or
- (D) the client, family, or guardian is aggrieved because of DHS actions to suspend, terminate, or reduce services.
- (2) All other complaints or grievances are made to OCA and are addressed in accordance with the policies and procedures of OCA.
- (3) Nothing contained in this subsection is construed as a limitation of the rights of class members regarding the review and appeal procedures set forth in the Consent Decree in Homeward Bound vs. The Hissom Memorial Center.
(d) Food Stamp Program. A hearing may be granted if:
- (1) the household's application is denied;
- (2) a decision regarding eligibility has not been reached within 30 days from the date of application;
- (3) a requested change in the amount of benefits has not been made within ten days from the request;
- (4) a decision regarding loss of benefits occurred in the previous 90 days; or
- (5) the household is aggrieved by:
- (A) reason of DHS interpretation and application of Food Stamp Program policy as applied to the household's situation during the certification period; or
- (B) any other action of DHS in its administration of the program which affects the household's participation.
(e) Individual and Family Disaster Grant Program. A hearing may be granted if:
- (1) the applicant's application is denied;
- (2) the applicant is dissatisfied with the amount of the grant award; or
- (3) there is an unreasonable delay relating to the application.
(f) Low Income Home Energy Assistance Program and Energy Crisis Assistance Program. A hearing may be granted if:
- (1) the applicant's application is denied;
- (2) there is a delay in reaching a decision regarding eligibility on an application for assistance of more than 30 days;
- (3) the client disagrees with the date on which assistance begins; or
- (4) the applicant is dissatisfied with the amount of the payment.
(g) Medical Assistance Program under Title XIX of the Social Security Act.
- (1) The Oklahoma Health Care Authority (OHCA) is the state agency authorized to operate Oklahoma's Medical Assistance Program pursuant to Title XIX of the Social Security Act. Through an interagency agreement with OHCA, DHS:
- (A) determines financial and non-financial eligibility for the Medical Assistance Program;
- (B) conducts hearings regarding:
- (i) financial and non-financial eligibility for the Medical Assistance Program; and
- (ii) the scope of services provided through the ADvantage Program waiver services; and
- (C) does not conduct hearings regarding:
- (i) the scope of services received for a person found eligible for the Medical Assistance Program, except as described in (B)(ii) of this subsection;
- (ii) payment for services;
- (iii) drug coverage for clients who are medically needy; or
- (iv) enrollment, disenrollment, and assignment within managed care plans.
- (2) Circumstances which constitute a basis for a hearing are:
- (A) the individual's application for medical services is denied;
- (B) a decision regarding eligibility has not been reached within the specified time limit from the date of the application:
- (i) five working days for presumptive eligibility for pregnant women;
- (ii) 20 days for:
- (I) categorically related to pregnancy related services; and
- (II) Medical Assistance only and categorically related to Aid to Families with Dependent Children;
- (iii) 30 days for:
- (I) Refugee Medical Assistance;
- (II) Categorically related to Aid to the Aged; and
- (III) Medical Assistance only and categorically related to Aid to Families with Dependent Children and establishing incapacity;
- (iv) 45 days for:
- (I) Medical Assistance Program only, not related to age, pregnancy or disability;
- (II) request for long-term care on an active State Supplement Payment (SSP) or Medical Assistance case;
- (III) Medical Assistance Program for optional tuberculosis (TB) coverage group; and
- (IV) Medical Assistance Program for long-term care request on active SSP for Aged, Blind, or Disabled cases;
- (v) 60 days for:
- (I) Medical Assistance Program only; or
- (II) categorically related to Aid to the Blind or Disabled;
- (C) the client disagrees with the date on which assistance begins; or
- (D) the client is dissatisfied with any other action affecting eligibility for Medical Assistance.
- (3) Administrative hearings are not granted when either state or federal law requires automatic adjustments for classes of recipients unless the reason for an individual appeal is incorrect eligibility determination.
(h) Social services under Title XX of the Social Security Act. A hearing may be granted if:
- (1) the client is aggrieved because of:
- (A) denial of a request for, or exclusion from, a service program;
- (B) failure to take account of the individual's choice of service in assignment of program; or
- (C) a decision requiring participation in a service program; or
- (2) the recipient is aggrieved about the operation of the service program.
(i) SSP for the Aged, Blind, and Disabled, and Temporary Assistance to Needy Families (TANF), including TANF Emergency Assistance.
- (1) A hearing is not granted in these programs when either state or federal law or regulation requires automatic grant adjustments for classes of recipients unless the reason for an individual appeal is incorrect grant computation.
- (2) A hearing may be granted when:
- (A) there is a delay in reaching a decision on an application for assistance of more than:
- (i) five working days for TANF Emergency Assistance;
- (ii) seven days for Diversion Assistance;
- (iii) 30 days for:
- (I) SSP for the Aged;
- (II) TANF; or
- (III) Refugee Cash Assistance;
- (iv) 45 days for SSP for the Blind; or
- (v) 60 days for SSP for the Disabled;
- (B) there is a delay of more than ten days in implementing a requested change regarding an assistance payment;
- (C) the client disagrees with the date on which assistance begins;
- (D) the assistance payment has been discontinued or suspended;
- (E) the client is aggrieved regarding protective payments because:
- (i) payment is made in the form of a protective payment; or
- (ii) of any action with regard to the protective payment, such as the protective payee selected; or
- (F) the client is aggrieved about conditions of payment, including the requirements for work, medical treatment, or training, but only if the requirement complained of, if true, would constitute a violation of DHS regulations.
(j) Assistance. In any other program which constitutes assistance within the definition of Section 164 of Title 56 of the Oklahoma Statutes, a hearing may be requested if the client disagrees with:
- (1) denial or termination of assistance;
- (2) amount of assistance; or
- (3) the conditions on receipt of benefits.
(k) Overpayments. If a client is notified of an overpayment in any of the programs listed in this Section, the client may request a hearing regarding:
- (1) the existence of the overpayment;
- (2) the amount of the overpayment;
- (3) when appropriate, whether the overpayment was caused due to Agency error, inadvertent client error, or willful misrepresentation by the client; and
- (4) when appropriate, the client's liability to repay the overpayment.