Section 7000, Applicant or Member Complaints, Internal MCO Appeals and State Fair Hearings

Revision 18-0; Effective September 4, 2018

 

7100 Managed Care Organization Procedures

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) must develop, implement and maintain a complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including Title 42 Code of Federal Regulations (CFR) §431 Subpart E, Fair Hearings for Applicants and Beneficiaries, and Title 42 CFR §438, Subpart F, Safeguarding Information on Applicants and Beneficiaries.

If an MCO makes a benefit determination adverse to the member, the member must exhaust the internal MCO appeal system prior to requesting a state fair hearing. If the Texas Health and Human Services Commission (HHSC) denies a member’s Medicaid or program eligibility, the member does not exhaust the internal MCO appeal system, as the MCO did not make the determination. Instead, the member requests a state fair hearing to appeal the HHSC decision.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, for PSU staff responsibilities related to state fair hearings.

 

7110 Managed Care Organization Complaint Procedures

Revision 18-0; Effective September 4, 2018


 
The Texas Health and Human Services Commission (HHSC) uses the term complaint to describe a grievance. Title 42 Code of Federal Regulations (CFR) §438.400(b)(7) defines a grievance as, “an expression of dissatisfaction about any matter other than an adverse benefit determination.” This definition also notes grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the [member’s] rights regardless of whether remedial action is requested. Grievance includes a [member’s] right to dispute an extension of time proposed by the [managed care organization (MCO)] to make an authorization decision.

If the member wants to file a complaint, he or she must first contact the MCO, following procedures specified in the MCO member handbook. The MCO provides a designated member advocate to:

If the member is not satisfied with the outcome of the MCO complaint process or the complaint is not resolved within 30 days, the member may contact the HHSC Ombudsman’s Managed Care Assistance Team at 866-566-8989 for assistance filing a complaint with HHSC. In addition, the member may send a written request to HHSC to investigate the complaint. The request is sent to:

Texas Health and Human Services Commission Managed Care Compliance & Operations (MCCO) – STAR Kids, 4900 North Lamar Blvd., Mail Code H320, Austin, TX 78751, or by email to HPM_Complaints@hhsc.state.tx.us.

 

7120 Internal Managed Care Organization Appeal Procedures

Revision 18-0; Effective September 4, 2018

 

In managed care, Title 42 Code of Federal Regulations (CFR) §438.400(b)(7) define an appeal as a review of a managed care organization (MCO) action, also called an adverse benefit determination. An adverse benefit determination is:

If a member, legally authorized representative (LAR), parent or guardian request to file an internal MCO appeal of an adverse benefit determination, the member must file an appeal by contacting the MCO following the procedures specified in the MCO member handbook or on the MCO notice of action. The member must request an internal MCO appeal no later than 90 days from the date of the MCO action. The MCO is required to regard any oral or written expression of dissatisfaction or disagreement related to an adverse benefit determination as a request to file an internal MCO appeal. The MCO must provide a designated member advocate to assist the member in filing an internal MCO appeal. The advocate must also assist the member by monitoring the internal MCO appeal throughout the process until the issue is resolved.

During the internal MCO appeal process, the MCO must provide the member with a reasonable opportunity to present evidence and any allegations of fact or law in person and in writing. The MCO must inform the member of the time available for providing this information. The MCO must provide the member the opportunity, before and during the internal MCO appeal process, to examine the member’s case file, including medical records and any other documents considered during the internal MCO appeal process.

As required by Title 42 CFR §438.420, the MCO must continue a member’s benefits pending the outcome of the internal MCO appeal if all the following criteria are met:

A member must request continued benefits no later than 10 days from the date of the MCO notice or date of the MCO proposed action.

 

7121 Expedited Managed Care Organization Internal Appeal

Revision 18-0; Effective September 4, 2018

 

In accordance with Title 42 Code of Federal Regulations (CFR) §438.410, the managed care organization (MCO) must establish and maintain an expedited review process for an adverse benefit determination when the MCO determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that the time for a standard internal MCO appeal could seriously jeopardize the member’s life or health. The MCO must follow all internal MCO appeal requirements for standard internal MCO appeals as set forth in the CFR. The MCO must accept oral or written requests for expedited internal MCO appeals.

 

After the MCO receives a request for an expedited internal MCO appeal, the MCO must notify the member or LAR of the outcome of the expedited internal MCO appeal request within 72 hours. However, the MCO must complete investigation and resolution of an internal MCO appeal relating to an ongoing emergency or denial of continued hospitalization:

The member must exhaust the expedited internal MCO appeal process before making a request for an expedited state fair hearing.

Except for an internal MCO appeal related to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited internal MCO appeal may be extended up to 14 days if the member requests an extension or the MCO shows (to the satisfaction of the Texas Health and Human Services Commission (HHSC), upon HHSC’s request) there is a need for additional information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.

If the internal MCO appeal determination is adverse to the member, the MCO must follow the procedures relating to the notice in the STAR Kids Managed Care Contract, Attachment B-1, Section 8.1.29.5. The MCO is responsible for notifying the member of his or her right to access an expedited state fair hearing. The MCO is also responsible for providing documentation to HHSC and the member, indicating how the determination was made, prior to HHSC’s expedited state fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member, provider or LAR for requesting an expedited internal MCO appeal or an expedited state fair hearing. The MCO must ensure punitive action is not taken against a provider who requests an expedited internal MCO appeal or supports a member’s request.

If the MCO denies a request for an expedited internal MCO appeal, the MCO must:

 

7122 Request for a State Fair Hearing After Exhausting Internal Managed Care Organization Appeals

Revision 18-0; Effective September 4, 2018

 

A member or legally authorized representative (LAR) may request a state fair hearing only after exhausting the internal managed care organization (MCO) appeal process.

The member must request a state fair hearing no later than 120 days from the date of the expedited internal MCO appeal.

In the case an MCO fails to adhere to the notice and timing requirements in Title 42 Code of Federal Regulations (CFR) §438.408, the member is deemed to have exhausted the internal MCO appeal process and may initiate a state fair hearing.

 

7200 State Fair Hearing Procedures for Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

 

 

 

7201 Timely or Non-timely State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

 

An applicant, member, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) may request a state fair hearing orally or in writing.

A timely state fair hearing request for a Medically Dependent Children Program (MDCP) eligibility denial is received by Program Support Unit (PSU) staff no later than 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for an MDCP eligibility denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

If a non-timely state fair hearing request is received from the applicant or member, PSU staff create the appeal in the Texas Integrated Eligibility Redesign System (TIERS). If the hearing officer determines there is good cause, the hearing officer will schedule a state fair hearing date. If the hearing officer determines if there is no good cause, the applicant or member is no longer eligible for a state fair hearing.

 

7210 Program Support Unit Staff Procedures for Completing Form H4800

Revision 18-0; Effective September 4, 2018


 
Program Support Unit (PSU) staff may receive a request for a state fair hearing related to Medically Dependent Children Program (MDCP) eligibility from an applicant, member, parent, guardian, or legally authorized representative (LAR) orally or in writing. When a state fair hearing request is received, PSU staff must create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, within five days from the date of the request.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials.

Upon receipt of the state fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary. PSU staff send Form H4800 to the data entry representative (DER) and DER supervisor within three days of the request for a state fair hearing. The three-day time frame allows the DER two days to enter the information on Form H4800 in TIERS.

PSU staff must use Form H4800 to record the names of all persons who should attend the state fair hearing.

Depending on the issue being appealed, PSU staff must enter the following staff on Form H4800:

PSU staff should contact the MCO if there is any doubt as to who should be listed on Form H4800.

When PSU staff complete Form H4800, all questions in Section 1 must be answered. PSU staff must always answer “No” to the question, “Appeal requested timely within 10 calendar days of agency action?”, as this question applies only to TW programs. PSU staff must indicate the individual service plan (ISP) begin and end dates, as applicable, in the section labeled “Summary of agency action and applicable handbook reference(s) or rules.”

PSU staff must indicate the ISP begin and end dates, as applicable, in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800. The begin and end dates must also be mentioned during the state fair hearing so the hearings officer is aware of when the ISP year ends when rendering a hearing decision regarding the MDCP denial.

Refer to Form H4800 instructions for more specific directions for form completion and transmittal.

 

7211 Data Entry Representative Procedures for Entering the State Fair Hearing Request

Revision 18-0; Effective September 4, 2018


 
When the data entry representative (DER) receives Form H4800, Fair Hearing Request Summary, from Program Support Unit (PSU) staff, the DER creates a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record to document the state fair hearing request. The HEART case record and Community Services Interest List (CSIL) database record is to remain open until a state fair hearing decision is rendered.

Within two business days of receipt of Form H4800, the DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS). The DER must use the Manage Office Resources (MOR) Search function in TIERS when adding PSU, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP) or Texas Health and Human Services Commission (HHSC) representatives as participants. When entry of all information is complete, TIERS assigns the appeal identification (ID) number. The DER sends a copy of the TIERS generated Form H4800 to PSU staff and uploads to the HEART case record.

 

7212 Generation of the State Fair Hearing Packet

Revision 18-0; Effective September 4, 2018


 
The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet, which is available to state fair hearing participants other than the applicant, member or legally authorized representative (LAR), such as Texas Health and Human Services Commission (HHSC), Texas Medicaid & Healthcare Partnership (TMHP), and managed care organization (MCO) staff. A partial state fair hearing packet includes:

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in TIERS that a state fair hearing has been scheduled. The alert in TIERS identifies the hearings officer assigned to the state fair hearing and the date and time of the state fair hearing. PSU staff use this information to monitor for the decision of the state fair hearing. PSU staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) financial denial.

Once a state fair hearing has been scheduled, TIERS generates a full state fair hearing packet, which the hearings officer mails to the applicant, member or LAR. A full state fair hearing packet includes:

 

7213 State Fair Hearing Packet

Revision 18-0; Effective September 4, 2018


 
Within 10 days, each entity involved in the state fair hearing is responsible for preparing its state fair hearing packet, uploading documents in the Texas Health and Human Services Commission (HHSC) Benefits portal, and mailing the documents to the applicant, member or legally authorized representative (LAR). Refer to Section 7231, Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal, for uploading instructions. Program Support Unit (PSU) staff must ensure documentation on Form H4800, Fair Hearing Request Summary, clearly states this is a state fair hearing for the Medically Dependent Children Program (MDCP). It is crucial that all state fair hearing packets are complete, organized and all pages numbered, in order to support the agency’s action on an appeal.

The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials.

The following are examples of documentation that must be submitted as evidence and the entity responsible for uploading that information in the HHSC Benefits Portal and mailing documents to the applicant, member, LAR or AR:

If an applicant, member, LAR or AR wants to submit evidence for the state fair hearing, the applicant, member, LAR or AR should fax or mail the evidence to the hearings officer. The hearings officer’s contact information is listed on Form H4803. Any evidence received from an applicant, member, LAR or AR is shared with HHSC.

 

7214 Changes to the State Fair Hearing Request Summary

Revision 18-0; Effective September 4, 2018


 
After the data entry representative (DER) has added information from Form H4800, Fair Hearing Request Summary, in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Woks (TW) financial denials, Program Support Unit (PSU) staff may learn of subsequent changes such as change of address. Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials. When subsequent changes occur, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the DER who will check TIERS to identify if a hearings officer has been assigned to the case. The DER must ensure documentation on Form H4800-A clearly states this is a state fair hearing for Medically Dependent Children Program (MDCP). The appeal identification (ID) number assigned by TIERS must be documented in the designated space on Form H4800-A.

If a hearings officer is assigned, the DER must upload Form H4800-A in the Texas Health and Human Services Commission (HHSC) Benefits Portal as soon as possible, but no later than 10 days of becoming aware of the change.

Delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.

 

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

 

 

 

7221 Type of Denials

Revision 18-0; Effective September 4, 2018

 

An applicant, member, parent, guardian or legally authorized representative (LAR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form H4800, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member, or legally authorized representative (LAR) requests a state fair hearing for program denials. PSU staff notify the Centralized Representative Unit (CRU) if it is a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial using the Texas Health and Human Services Commission (HHSC) Benefits Portal. PSU staff create all other state fair hearing request in TIERS. The method in which the state fair hearing is requested depends on the action being appealed. PSU staff must determine if the state fair hearing action is:

 

7221.1 Medical Necessity Denial by Texas Medicaid & Healthcare Partnership

Revision 18-0; Effective September 4, 2018

 

If the action is related to a medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP), the managed care organization (MCO) and TMHP representatives are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff upload Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available), to the Texas Health and Human Services Commission (HHSC) Benefits portal to allow the TMHP representative to include Form H2065-D in TMHP’s evidence packet. PSU staff do not attend state fair hearings for MN denials.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the TMHP representative and TMHP supervisor as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "Observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an MN denial, on the “Agency Representative” field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

When Form H4800 is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while an MN denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the MN denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, PSU staff and the PSU supervisor entered as "Observer" are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.2 Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 18-0; Effective September 4, 2018

 

If the state fair hearing decision is related to a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial for a medical assistance only (MAO) applicant or member, Program Support Unit (PSU) staff must forward the request to the Centralized Representation Unit (CRU). The CRU is required to attend the state fair hearing to represent Medically Dependent Children Program (MDCP) financial denials.

Within one business day of receipt of the request, PSU staff must create the following:

Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

Once the CRU receives a state fair hearing request, the CRU sends an email reply to PSU staff and the PSU supervisor listed as "Observers" within five days, notifying of the completion of Form H4800 and the appeal identification number (ID). Once PSU staff receives the notification, PSU staff upload the notification in HEART and monitor the appeal until the state fair hearing decision is rendered. PSU staff must not put an applicant or member name back on the MDCP program interest list while an MEPD or TW financial denial are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the MEPD or TW financial denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, PSU staff and the PSU supervisor entered as "Observer" are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision 18-0; Effective September 4, 2018

 

If the action is related to a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA), Program Support Unit (PSU) staff are required to prepare the evidence packet and attend the state fair hearing. Refer to Section 7230, State Fair Hearing Actions, for PSU staff responsibilities for preparing the state fair hearing evidence packet.

The following are examples of documentation that must be submitted as evidence and PSU staff are responsible for uploading that information in the Texas Health and Human Services (HHSC) Benefits Portal:

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the PSU staff and PSU supervisor as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the “Agency Representative" and “Agency Representative Supervisor” will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an SSI denial, on the "Agency Representative" field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for SSI denials. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while an SSI denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the SSI denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as "Agency Representative" and “Agency Representative Supervisor” are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.4 Other Denial Reasons

Revision 18-0; Effective September 4, 2018

 

Other denial reasons include, but not limited to:

If the action is related to other denial reasons, the managed care organization (MCO) staff are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff do not attend state fair hearings related to other denial reasons.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the MCO contact as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "Observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to other denial reasons, on the "Agency Representative" field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

When Form H4800 is sent to the data entry representative (DER), PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while other denial reasons are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the other denial reasons state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as "Observer” are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7222 Continuation or Termination of Services

Revision 18-0; Effective September 4, 2018

 

 

 

7222.1 Continuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 18-0; Effective September 4, 2018

 

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for Supplemental Security Income (SSI) denials. For all other denials, MDCP services must continue until the hearings officer issues a decision regarding the state fair hearing of a member, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. If the state fair hearing was requested by the effective date of the action, within three business days, Program Support Unit (PSU) staff must notify:

If the hearings officer’s decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four months or until the state fair hearing decision is rendered. PSU staff do not mail Form H2065-D to the member or LAR notifying of continued eligibility related to the reassessment action taken to continue services until the state fair hearing decision is rendered.

Example: If an ISP expiration date is on December 1 and the state fair hearing decision is on December 15, then a four-month period would end on the last day of April.

If the state fair hearing is initially dismissed and subsequently reopened, the Texas Health and Human Services Commission (HHSC) continues or reinstates services pending the state fair hearing decision, if the member or LAR requests continued services. When the hearings officer sets a date for a new state fair hearing, the hearings officer, in effect, voids the prior state fair hearing decision. Because services are continued until a decision is rendered, and the hearings officer is stating there is still a state fair hearing to be held, HHSC continues or reinstates services again.

 

7222.2 Termination of MDCP Services Due to a Member Not Requesting a State Fair Hearing

Revision 18-0; Effective September 4, 2018

 

If the state fair hearing is not filed by the effective date of the action, Medically Dependent Children Program (MDCP) services continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If the state fair hearing was not requested by the effective date of the action, Program Support Unit (PSU) staff must process according to the following:

SSI members will remain enrolled in a STAR Kids MCO and are still eligible for State Plan services, which include acute care and long term services and supports (LTSS), such as Community First Choice (CFC), Day Activity and Health Services (DAHS), Emergency Response Services (ERS), and personal assistance services (PAS).

 

7230 State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

 

 

 

7231 Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal

Revision 18-0; Effective September 4, 2018


 
The data entry representative (DER) must upload all evidence packets and all supporting documentation for Supplemental Security Income (SSI) denials and medical necessity (MN) denials in the Texas Health and Human Services Commission (HHSC) Benefits Portal using the process described below. Refer to Section 7213, State Fair Hearing Packet, for examples of documentation that must be submitted as evidence.

At least 12 business days prior to the state fair hearing date, the DER must:

Within two business days after receipt of the evidence packet in the HHSC Benefits Portal, the DER must:

If an error is made on the “Agency Representative” screen when creating an appeal in the Texas Integrated Eligibility Redesign System (TIERS), the person who created the appeal can correct the error in “Maintain Appeals.” If an error is made on any other screen when creating an appeal in TIERS, Form H4800-A, Fair Hearing Request Summary (Addendum), must be completed and uploaded in the HHSC Benefits Portal. The “Agency Action Date” cannot be changed.

 

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 18-0; Effective September 4, 2018

 

Documentation contained in the evidence packet is not considered in the state fair hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, the “Agency Representative” listed on Form H4800, Fair Hearing Request Summary, must present the packet, ask that the documents be admitted as evidence and summarize what the packet contains. PSU staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) denial. Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration, for PSU staff state fair hearing responsibilities. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case.

MCO Example: "I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

PSU Example: "I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

The hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the hearings officer explains the reasons for excluding the material. Any documents admitted by the hearings officer are considered when a decision is rendered.

 

7233 State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018


 
After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or legally authorized representative (LAR) and copies all individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff and the PSU supervisor. If the decision is sustained, the PSU staff take the appropriate action.

If the state fair hearing decision is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The hearings officer renders a decision and sends the written decision to the applicant, member or LAR and copies all the individuals listed on Form H4800, which includes the PSU staff and PSU supervisor. PSU staff actions required by the hearings officer must be reported back in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation screen, within the 10-day time frame designated by the hearings officer.

If the applicant, member or LAR requested continued services during the state fair hearing period, PSU staff follow procedures described in Section 7500, State Fair Hearing Decision Actions.

 

7300 Post State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

 

 

 

7310 Action Taken on the State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018


 
Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the PSU supervisor and data entry representative (DER). PSU staff must send Form H4807 within the 10-day time frame designated by the hearings officer to allow at least two business days for the DER to enter the information in the Texas Integrated Eligibility Redesign System (TIERS). If the action cannot be taken within the time frame designated by the hearings officer, Form H4807 is completed and sent to the PSU supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on Form H4807; the begin delay date and end delay date must be included. Refer to Form H4807 instructions for more specific directions for form completion and transmittal.

 

7400  Reserved for Future Use

Revision 18-0; Effective September 4, 2018

 

 

 

7500 State Fair Hearing Decision Actions

Revision 18-0; Effective September 4, 2018

 

 

 

7510 Sustained State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018


 
When a hearings officer renders a sustained decision, the denial is upheld. If an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal (request for the state fair hearing), essentially sustaining the action on appeal. Refer to Section 7511, Sustained Decision Termination Effective Date, to determine the correct Medically Dependent Children Program (MDCP) termination effective date to include on forms and notifications.

When the hearings officer’s decision sustains the denial of MDCP, Program Support Unit (PSU) staff must:

PSU staff must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, member authorized representative (AR) or legally authorized representative (LAR) of the sustained denial.

 

7511 Sustained Decision – Termination Effective Date

Revision 18-0; Effective September 4, 2018


 
When Medically Dependent Children Program (MDCP) services are terminated at reassessment because the applicant or member does not meet eligibility criteria and services are continued until the state fair hearing decision is known, the termination effective date will vary depending on the following circumstances:

Examples

Example Conditions Original
MN/ISP
Expiration
Date
New Expiration
Date
Hearings Officer
Decision Date
Final
MN/ISP Expiration
Date
1 Hearings officer decision is more than 30 days from the original expiration date. 1/31/18 5/31/18 11/30/17 1/31/18
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/18 5/31/18 1/15/18 2/28/18
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/18 5/31/18 2/15/18 3/31/18
4 Hearings officer decision assigns a specific expiration date. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/15/18. 2/28/18
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/28/18. 2/29/18
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 12/31/17. 1/31/18

 

7520 Reversed State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018


 
When the hearings officer’s decision reverses the denial of the Medically Dependent Children Program (MDCP) for an applicant or member, within two business days Program Support Unit (PSU) staff must:

 

7521 Reversed Decision – Effective Date

Revision 18-0; Effective September 4, 2018


 
When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) eligibility, the effective date for:

When a state fair hearing decision reverses a Program Support Unit (PSU) program denial but PSU staff cannot implement the state fair hearing decision within the required time frame, PSU staff must complete Section C, Implementation Delays, on Form H4807, Action Taken on Hearing Decision. PSU staff must attach and send Form H4807 by email to the data entry representative (DER). Information on Form H4807 must be entered by the DER on the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Refer to Section 7233, State Fair Hearing Decision, and Section 7310, Action Taken on the State Fair Hearing Decision, for the required time frames.

PSU staff may need to coordinate effective dates of reinstatement with the Central Representation Unit (CRU).

PSU staff report the implementation of the state fair hearing decision in TIERS on Form H4807 according to current procedures.

 

7522 New Assessment Required by State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018


 
If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed as a result of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must indicate in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800, Fair Hearing Request Summary, and also during the state fair hearing that the new assessment was ordered from a previous state fair hearing decision.

If the member or LAR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a Medically Dependent Children Program (MDCP) member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving prior to the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member or LAR informing him or her of the MN denial. The member or LAR then request another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided prior to the first state fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member or LAR requests a state fair hearing due to the lower RUG level, the MCO continues services at the same level services were provided prior to the first state fair hearing.

 

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018


 
An applicant, member or legally authorized representative (LAR) may withdraw the state fair hearing request orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing. If the applicant, member or LAR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or LAR to contact the hearings officer of the withdrawal by calling the hearings officer’s telephone number listed on Form H4803. If the applicant, member or LAR send a written request to withdraw to PSU staff, PSU staff must forward the written request to the hearings officer listed on Form H4803.

A state fair hearing will not be dismissed based on a PSU staff decision to change the adverse action. All requests to withdraw the state fair hearing must originate from the applicant, member or LAR and must be made to the hearings officer.

If the applicant, member or LAR request to withdraw the state fair hearing more than five business days prior to the state fair hearing date, the hearings officer will process the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written decision to participants informing them of the state fair hearing cancellation.

If the applicant, member or LAR request to withdraw the state fair hearing within five business days of the state fair hearing date, the hearings officer will notify PSU staff by telephone or email and open the conference line to inform participants of the cancellation.

 

7600 Roles and Responsibilities of Texas Health and Human Services Commission Hearings Officer

Revision 18-0; Effective September 4, 2018


 
The Texas Health and Human Services Commission (HHSC) hearings officer:

Administrative review of any hearings officer’s decision provided in the state fair hearings must be initiated by the applicant, member or LAR.