7000, Applicant or Member Complaints and State Fair Hearings

7210 Timely or Non-timely State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

Only an applicant, member, guardian or authorized representative (AR) may request a state fair hearing. The applicant, member or AR may request a state fair hearing orally or in writing.

A timely state fair hearing request for a STAR+PLUS Home and Community Based Services (HCBS) program denial is received by Program Support Unit (PSU) staff within 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for a STAR+PLUS HCBS program denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

PSU staff must create the appeal in the Texas Integrated Eligibility Redesign System (TIERS) for all state fair hearing requests that are received, except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. PSU staff must notify the Centralized Representative Unit (CRU) by creating an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits Portal if a fair hearing request is received for a MEPD or TW financial denial. PSU staff or the data entry representative (DER) must refer to Appendix XXI, Creating an Appeal in TIERS, and Appendix XXXII, Creating an Appeal Task in the HHSC Benefits Portal, when creating records.

The hearings officer will determine if there is good cause for a non-timely state fair hearing request. The applicant or member is not eligible for a state fair hearing if the hearings officer determines there is no good cause.

7211 PSU Staff Procedures for Completing Form 4800-D

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive an oral or written appeal request related to STAR+PLUS Home and Community Based Services (HCBS) program eligibility denial or termination from an:

applicant;
member; or
authorized representative (AR).

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 a fair hearing request is received.

PSU staff must complete the following activities within three days of receipt of the state fair hearing request:

complete Form 4800-D, Fair Hearing Request Summary, ensuring all persons who should attend the state fair hearing are documented; and
email Form 4800-D to the data entry representative (DER) and DER supervisor.

The DER must enter the information on Form 4800-D in TIERS within two days.

Depending on the issue being appealed, PSU staff must enter the following staff on Form 4800-D:

For medical necessity/level of care (MN/LOC) denial by Texas Medicaid & Healthcare Partnership (TMHP):
- TMHP representative as the Agency Representative;
- TMHP supervisor as the Agency Supervisor;
- managed care organization (MCO) representative and MCO supervisor as the Agency Witness; and
- PSU staff and PSU supervisor as the Observer.
For Supplemental Security Income (SSI) denial by Social Security Administration (SSA):
- PSU staff as the Agency Representative;
- PSU supervisor as the Agency Supervisor;
- no Agency Witness is entered; and
- MCO representative and MCO supervisor as the Observer
For other denial reasons (excluding MEPD or TW financial denials):
- MCO representative as the Agency Representative;
- MCO supervisor as the Agency Supervisor;
- MCO representative as the Other Participants; and
- PSU staff and PSU supervisor as the Observer.

PSU staff must contact the MCO if there is any doubt as to who should be listed on Form 4800-D.

PSU must complete the following activities when completing Form 4800-D:

answer all questions in Section 3, Appellant Details Programs;
always answer “No” to the question, “Is there a good cause for non-timely?” in Subsection D, Summary of Agency Action and Citation, since this question only applies to TW programs; and
indicate the individual service plan (ISP) begin and end dates, as applicable, in Subsection D.

PSU staff must refer to Form 4800-D instructions for more specific directions for form completion and transmittal.

PSU staff must refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

7212 DER Procedures for Entering State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

The data entry representative (DER) creates a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to document the state fair hearing request when the DER receives Form 4800-D, Fair Hearing Request Summary, from Program Support Unit (PSU) staff. The HEART case record and Community Services Interest List (CSIL) record must remain open until a state fair hearing decision is rendered.

The DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form 4800-D, following the instructions in Appendix XXI, Creating an Appeal in TIERS. The DER must use the Manage Office Resources (MOR) search function in TIERS when adding PSU staff, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP), or Texas Health and Human Services Commission (HHSC) representatives as participants. TIERS will assign an appeal identification (ID) number once the DER completes all required fields. The DER must send a copy of the TIERS generated Form H4800, Fair Hearing Request Summary, to PSU staff and upload a copy to the HEART case record.

7213 Generation of the State Fair Hearing Packet

Revision 19-13; Effective November 5, 2019

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 authorized representative (AR), such as Texas Health and Human Services Commission (HHSC), the managed care organization (MCO) or Texas Medicaid & Healthcare Partnership (TMHP). A partial state fair hearing packet includes:

Form H4800, Fair Hearing Request Summary; and
Form H4803, Notice of Hearing.

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 sends to the applicant, member or AR. A full state fair hearing packet includes:

Form H4800;
Form H4803;
Fair Hearing Procedures (PDF); and
Form H4806, Request for Another Appointment - Request to Withdraw.

7214 State Fair Hearing Evidence Packet

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must complete the following activities on the same day PSU staff enter the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS):

prepare a state fair hearing evidence packet;
mail the state fair hearing evidence packet to the applicant, member or authorized representative (AR);
upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal following the instructions in Section 7231, Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal;
upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
document the HEART case record.

PSU staff must not enter state fair hearing requests for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) Medicaid financial denials. The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to MEPD and TW financial denials. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

PSU staff must ensure documentation on Form 4800-D, Fair Hearing Request Summary, clearly states the state fair hearing is for the STAR+PLUS Home and Community Based Services (HCBS) program.

The STAR+PLUS HCBS state fair hearing evidence packet includes:

Form 4801, State Fair Hearing Evidence Packet Cover Page;
Form H2065-D, Notification of Managed Care Services;
the appropriate handbook section, as notated on Form H2065-D;
Appendix XX, STAR+PLUS HCBS Program Eligibility TAC; and
for MN/Level of Care (MN/LOC) denials or terminations, Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment.

PSU staff must ensure all state fair hearing evidence packets are complete, organized and all pages are numbered to support the agency’s action on appeal.

Other agencies that may be involved in a state fair hearing, such as the managed care organization (MCO), Centralized Representation Unit (CRU) or Texas Medicaid & Healthcare Partnership (TMHP) will:

generate their own state fair hearing evidence packet;
upload their state fair hearing evidence packet to the HHSC Benefits Portal; and
mail their state fair hearing evidence packet to the applicant, member or AR.

The hearings officer mails Form H4803 to the applicant, member or AR when the state fair hearing is first requested. The applicant, member or AR may fax or mail evidence to the hearings officer if desired. The applicant, member or AR gets the hearings officer’s contact information from Form H4803, Notice of Fair Hearing. The hearings officer shares any evidence submitted by the applicant, member or AR with HHSC.

7215 Changes to the State Fair Hearing Request Summary

Revision 24-4; Effective Dec. 1, 2024

Program Support Unit (PSU) staff may learn of changes to an applicant or member’s information after entering the fair hearing into the Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must complete the following activities as soon as possible but by five days from notification of the change:

complete Form H4800-A, Fair Hearing Request Summary - Addendum (PDF), with the updated information; and
email Form H4800-A to the data entry representative (DER).

PSU staff must include the following on Form H4800-A:

a clear statement showing that this is a state fair hearing for STAR+PLUS Home and Community Based Services (HCBS) program; and
the appeal ID number assigned by TIERS in the designated field on Form H4800-A.

The DER must complete the following activities as soon as possible but no later than five days from the PSU staff notification:

verify that a hearings officer has been assigned to the case by checking TIERS;
upload Form H4800-A to the Texas Health and Human Services Commission (HHSC) State Portal;
notify the hearings officer by email which must include the following:
- an email subject line that reads: Form H4800-A for XX [first letter of the applicant’s or member’s first and last name];
- applicant or member’s name;
- Social Security number (SSN) or Medicaid identification (ID) number, as applicable;
- HHSC State Portal appeal ID number;
- the type of request such as notification of a change; and
- Form H4800-A as an attachment.
upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
document the HEART case record.

The DER may also email Form H4800-A to the hearings officer if they encounter issues with uploading Form H4800-A to the HHSC State Portal.

PSU staff delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.

Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for appeal requests related to Medicaid for Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denials.

7220 Processing a State Fair Hearing Request

Revision 19-13; Effective November 5, 2019

7221 Type of Denials

Revision 19-13; Effective November 5, 2019

An applicant, member, guardian or authorized representative (AR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member or AR 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:

a medical necessity (MN) denial (Refer to Section 7221.1, Medical Necessity Denial by TMHP) below;
a financial denial by MEPD or TW (Refer to Section 7221.2, Financial Denial by MEPD or TW);
a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA) (Refer to Section 7221.3, SSI Denial by the SSA; or
for any other denial reasons (Refer to Section 7221.4, Other Denial Reasons).

7221.1 Medical Necessity Denial by TMHP

Revision 19-13; Effective November 5, 2019

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:

TMHP representative as the Agency Representative;
TMHP supervisor as the Agency Representative Supervisor;
MCO representative and MCO supervisor as the Agency Witness; and
PSU staff and PSU supervisor as the Observer.

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, 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 menu.

When Form 4800-D 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 STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the STAR+PLUS HCBS program 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 STAR+PLUS HCBS program 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 7400, 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 MEPD or TW

Revision 24-4; Effective Dec. 1, 2024

Program Support Unit (PSU) staff must forward the request for a state fair hearing to the Centralized Representation Unit (CRU) if the denial is for a medical assistance only (MAO) applicant or member who does not meet financial criteria through the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) programs. The CRU must attend the state fair hearing to represent STAR+PLUS Home and Community Based Services (HCBS) program financial denials.

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

an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits portal in the Appeals/RFR tab for the CRU about a financial denial for an MAO applicant or member;
- Refer to Appendix XXXII, Create an Appeal Task in the HHSC Benefits Portal;
an email to the CRU at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox that includes:
- a subject line that reads: STAR+PLUS HCBS Program Appeal Request – XX [first letter of the applicant’s or member’s first and last name];
- applicant or member’s name;
- Medicaid identification (ID) number or Social Security number (SSN);
- Texas Integrated Eligibility Redesign System (TIERS) Case Number;
- program type: STAR+PLUS HCBS program;
- timeliness of receipt of the appeal;
- specific information requesting the MEPD or TW financial denial case remain open during the state fair hearing, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing;
- observers contact information noted as the PSU staff and PSU supervisor; and
- a copy of Form H2065-D, Notification of Managed Care Program Services (PDF), a signed copy if available;
a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) documenting:
- the receipt date of the state fair hearing request; and
- notification to the CRU for completion of Form H4800, Fair Hearing Request Summary (PDF).

Refer to Section 7222.1, Continuation of STAR+PLUS HCBS 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 4800 and the appeal identification number (ID). PSU staff must upload the notification in the HEART case record and monitor the appeal until the state fair hearing decision is rendered once PSU staff receive the notification.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS 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 STAR+PLUS HCBS program interest list if the denial is sustained.

PSU staff and the PSU supervisor entered as Observers are notified by an email alert from TIERS of the decision by the hearings officer when a state fair hearing decision is rendered by the hearings officer.

Refer to Section 7400, State Fair Hearing Decision Actions, for more information about required actions following the decision of a state fair hearing.

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must prepare the evidence packet and attend the for Supplemental Security Income (SSI) denials by the Social Security Administration (SSA). 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 PSU staff must submit as evidence and are responsible for uploading in the Texas Health and Human Services (HHSC) Benefits Portal:

Form H4803, Notice of Hearing, as a cover sheet;
copy of the citation, Title 1 Texas Administrative Code (TAC) Section 353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
Section 6200.4, Financial Eligibility; and
Form H2065-D, Notification of Managed Care Program Services.

Refer to Appendix XXI, Creating an Appeal in TIERS, for more information on PSU staff completion of Form H4800, Fair Hearing Request Summary.

Continuation of STAR+PLUS HCBS program benefits during a state fair hearing does not apply to SSI denials. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for more information. PSU staff must not return an applicant or member to the STAR+PLUS HCBS program 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 hearings officer renders a decision on the SSI denial. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the hearings officer sustains the denial.

The PSU staff and PSU supervisor entered as “Agency Representative” and “Agency Representative Supervisor” receive an alert in TIERS when the hearings officer renders a state fair hearing decision.

Refer to Section 7400, State Fair Hearing Decision Actions, for more information about notification requirements for required actions following a state fair hearing decision.

7221.4 Other Denial Reasons

Revision 19-13; Effective November 5, 2019

Other denial reasons include, but are not limited to:

unable to locate the applicant or member;
unable to obtain physician signature; or
cost of the individual service plan (ISP) exceeds the maximum amount allowed.

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. PSU staff do not attend state fair hearings related to other denial reasons.

Program Support Unit (PSU) staff complete Form 4800-D, Fair Hearing Request Summary, entering the MCO staff as the Agency Representative and Agency Representative Supervisor.

MCO staff as the Agency Representative;
MCO supervisor as the Agency Representative Supervisor;
MCO staff as the Agency Witness; and
PSU staff and PSU supervisor as the Observer.

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 will be required to select "No" in the drop-down menu.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS program 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 reason state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program 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 7400, 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 19-13; Effective November 5, 2019

7222.1 Continuation of STAR+PLUS HCBS Program During a State Fair Hearing

Revision 24-4; Effective Dec. 1, 2024

The STAR+PLUS HCBS program must continue until the hearings officer issues a decision if the member or authorized representative (AR) files a state fair hearing requesting continued benefits:

within the adverse action notification period of the STAR+PLUS HCBS program termination; or
by the effective date of the action pending the state fair hearing.

The deadline is the later date.

Continuation of STAR+PLUS Home and Community Based Services (HCBS) program benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials.

Refer to Section 6200, Adverse Action Notification Period, for more information about the adverse action notification period.

Program Support Unit (PSU) staff must complete the following activities within five business days of the member requesting a state fair hearing within the adverse action notification period or by the effective date of the action:

extend the current individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) in four calendar month intervals until the fair hearing decision is rendered if the hearings officer’s decision will not be made until after the ISP expires;
- PSU staff must not extend the medical necessity and level of care (MN/LOC) records in the Service Authorization System Online (SASO);
- Example: The member’s four-month period would end on April 30, 2023, if the ISP expiration date is Dec. 31, 2022, and the state fair hearing decision date will not be made until after Dec. 31, 2022;
upload Form H2067-MC, Managed Care Programs Communication (PDF), to the MCOHub notifying the managed care organization (MCO) to continue to provide services until the hearings officer renders a decision;
email the Centralized Representation Unit (CRU) at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox the following information:
- an email subject line that reads: STAR+PLUS HCBS Request for Continued Benefits – XX [first letter of the member’s first and last name] #### [last four digits of the case number];
- member’s name;
- Medicaid identification (ID) number;
- HHSC Benefits Portal Appeal ID number, if available;
- Texas Integrated Eligibility Redesign System (TIERS) Case Number;
- type of service: STAR+PLUS HCBS program;
- reason for termination such as a medical necessity (MN) denial;
- specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial case remain open during the state fair hearing;
  - For example, the MEPD or TW financial denial case may need to remain open pending a state fair hearing decision about MN;
- a copy of Form H2067-MC, Managed Care Programs Communication (PDF), from the MCO indicating the member requested continued benefits, if applicable;
- a copy of Form H2065-D, Notification of Managed Care Program Services (PDF); and
- the witnesses’ contact information, such as the MCO representative and the designated MCO back-up; and
upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
document the HEART case record; and
monitor the case for the receipt of the TIERS alert indicating the hearings officer’s decision.

PSU staff must not mail Form H2065-D to the member or authorized representative (AR) notifying of continued STAR+PLUS HCBS program services until the hearings officer renders a state fair hearing decision.

HHSC continues services pending the state fair hearing decision if the state fair hearing is initially dismissed and then subsequently reopened and the member or AR requests continued services. The hearings officer voids the prior state fair hearing decision if the hearings officer sets a date for a new state fair hearing. The member must continue to receive services until the hearings officer renders a new state fair hearing decision.

7222.2 Discontinuation of STAR+PLUS HCBS Program Due to Member Not Requesting a State Fair Hearing

Revision 24-4; Effective Dec. 1, 2024

A member’s STAR+PLUS Home and Community Based Services (HCBS) program services must continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services (PDF). The program denial date is the last day of the month of the current individual service plan (ISP) or the last day of the month that the adverse action notification period ends, whichever is later. Refer to Section 6200, Adverse Action Notification Period, for more information.

A member who does not request a state fair hearing with continued benefits before the effective date of the denial will not receive continued STAR+PLUS HCBS program services during the state fair hearing. Program Support Unit (PSU) staff must monitor the case for the receipt of the Texas Integrated Eligibility Redesign System (TIERS) alert indicating the hearings officer’s decision.

Supplemental Security Income (SSI) members will remain enrolled in STAR+PLUS after STAR+PLUS HCBS termination. SSI members remain eligible for Medicaid 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 19-13; Effective November 5, 2019

7231 Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal

Revision 19-13; Effective November 5, 2019

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, Generation of the 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:

upload the supporting documentation in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
email the supporting documentation to Program Support Unit (PSU) staff and the PSU supervisor.

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

select the Appeals/RFR tab and ensure the appeal has been entered;
select Hearing Evidence Packets Upload and enter the appeal identification (ID) number;
select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
select Validate;
check the details to ensure the right person has been selected;
browse for the document (e.g., Form H2065-D, Notification of Managed Care Program Services); and
select Upload.

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 22-1; Effective January 31, 2022

The hearings officer will not consider documentation in the evidence packet in the state fair hearing decision unless the packet is offered and admitted into evidence. 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. Program Support Unit (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 behalf of Ned Flanders.

Pages 1-10 contain information relating to the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide.
Pages 11-15 contain policy from the STAR+PLUS Handbook (SPH) that relates directly to the issue in question.
Pages 16-20 contain documents signed by the applicant, member or authorized representative (AR) related to individual rights.
Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or authorized representative (AR) on March 2."

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

Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
Page 2 contains a copy of the Title 1 Texas Administrative Code (TAC) §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program, that states the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR+PLUS HCBS program services to eligible applicants or members.
Page 3 contains a copy of the SPOPH Section 6200.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR+PLUS HCBS program services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) requirements.
Page 4 contains Form H2065-D, which was mailed to the applicant, member or AR on March 2nd."

The hearings officer then asks for objections and admits the documents into evidence. The hearings officer explains the reasons for excluding the material if the hearings officer is not able to admit any documents. The hearings officer considers any documents admitted when rendering a decision.

7233 State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or authorized representative (AR) 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, 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 AR 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 AR requested continued services during the state fair hearing period, PSU staff follow procedures, as described in Section 7400, State Fair Hearing Decision Actions.

Revision Notice 23-3; Effective Aug. 21, 2023

State fair hearing decision terminology used by the hearings officer is defined below:

Sustained – This decision type is used when the hearings officer determines HHSC’s action was appropriate per policy and law.
Sustained with Instructions – This decision type is used when the hearings officer determines HHSC’s action was appropriate per policy and law, however new information has been provided and more action is required.
Reversed – This decision type is used when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate services.

7410 Sustained State Fair Hearing Decision

Revision 24-2; Effective May 21, 2024

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for applicants and members who did not request continued benefits.

PSU staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued STAR+PLUS Home and Community Based Services (HCBS) program benefits:

upload Form H2067-MC, Managed Care Programs Communication (PDF), to the MCOHub notifying the managed care organization (MCO) that the:
- hearing decision sustained the action on appeal; and
- MCO must deliver services through the STAR+PLUS HCBS program termination effective date;
terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7411, Sustained Decision – Termination Effective Date;
close the Community Services Interest List (CSIL) record if the record is open;
email the Centralized Representation Unit (CRU) Unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox for medical assistance only (MAO) members;
- the email to the CRU Unit must include the following information:
  - an email subject line that states: “Sustained Denial for STAR+PLUS HCBS – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”;
  - the member's name;
  - Medicaid identification (ID) number;
  - the type of request for example notification of sustained denial of the STAR+PLUS HCBS program;
  - the type of service such as STAR+PLUS HCBS program;
  - HHSC Benefits Portal appeal ID number;
  - the Texas Integrated Eligibility Redesign System (TIERS) case number;
  - STAR+PLUS HCBS program termination effective date; and
  - the state fair hearing decision;
upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services (PDF), Notification of Managed Care Program Services (PDF), to notify the applicant, member, or authorized representative (AR) of a sustained denial or termination.

7411 Sustained Decision – Termination Effective Date

Revision 19-13; Effective November 5, 2019

When the STAR+PLUS Home and Community Based Services (HCBS) program is terminated at reassessment because the 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:

In cases where the hearings officer's decision is 30 days or more prior to the end of the individual service plan (ISP) in effect when the state fair hearing was filed, STAR+PLUS HCBS program termination is effective at the end of the ISP in effect at the time the state fair hearing was filed. Refer to Example 1 below.
When the hearings officer’s decision date is less than 30 days before the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date (the date the order is signed). Refer to Example 2 below.
When the hearings officer's decision date is after the end of the ISP in effect when the state fair hearing was filed, and a new ISP was developed to continue services past the ISP end date until the state fair hearing decision was made, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date. Refer to Example 3 below.
If the hearings officer assigns a specific medical necessity (MN) or ISP expiration date not equal to the last day of the month, but after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that the hearings officer identified as the expiration month. Refer to Example 4 below.
When the hearings officer assigns a specific MN or ISP expiration date equal to the last day of the month, and this date is equal to or after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of that ISP period. Refer to Example 5 below.
If the hearings officer assigns a specific MN or ISP expiration date that is before the end of the MN or ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month of the original MN or ISP expiration date. Refer to Example 6 below.

Examples

Example	Conditions	Original MN or ISP Expiration Date	New Expiration Date	Hearings Officer Decision Date	Final MN or 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.	2/18/18
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.	2/18/18
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

7420 Reversed State Fair Hearing Decision

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the hearings officer’s decision to reverse the denial or termination of STAR+PLUS Home and Community Based Services (HCBS) program within two business days by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. PSU staff must notate the following on Form H2067-MC:

STAR+PLUS HCBS program services are to continue as directed in the hearings officer’s decision, as applicable; and
the MCO must upload a new ISP to TxMedCentral or to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), as applicable.

PSU staff must complete the following activities for applicants within two business days of receipt of the ISP:

manually generate Form H2065-D, Notification of Managed Care Program Services;
- for all applicants, the ISP begin date will be the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
mail Form H2065-D to the applicant;
upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV;
ensure the ISP is updated in the Service Authorization System Online (SASO) with the correct effective dates by following the instructions in Section 9000, Service Authorization System Online Help File;
for medical assistance only (MAO) applicants, notify Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
- a subject line that reads: Reversed Hearing Decision – STAR+PLUS HCBS Appeal for XX [first letter of the applicant’s first and last name]. For example, the email subject line for a STAR+PLUS HCBS program termination reversal for Ann Smith would be “Reversed Hearing Decision – STAR+PLUS HCBS Appeal for AS”;
- the applicant’s name;
- Medicaid identification (ID) number or Social Security number (SSN);
- Health and Human Services Commission (HHSC) Benefits portal Appeal ID number;
- Texas Integrated Eligibility Redesign System (TIERS) case number;
- ISP receipt date;
- ISP begin date;
- ISP end date;
- TIERS Medicaid eligibility effective date;
- TIERS managed care effective date;
- Form H2065-D; and
- the state fair hearing decision;
for MAO applicants, notify Centralized Representation Unit (CRU) staff by email at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to CRU staff must include:
- o a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the applicant’s first and last name];
- o the applicant’s name;
- o Medicaid ID number or SSN;
- o type of request (i.e., continue or reinstate Medicaid eligibility);
- o type of service (i.e., STAR+PLUS HCBS program);
- o HHSC Benefits portal Appeal ID number;
- o TIERS case number;
- o TIERS Medicaid eligibility effective date;
- o Form H1746-A , MEPD Referral Cover Sheet;
- o Form H2065-D; and
- o the state fair hearing decision;
upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XXXIII , STAR+PLUS HEART Naming Conventions; and
document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of receipt of the ISP:

electronically generate Form H2065-D in the TMHP LTCOP;
- for a member who did not receive continued benefits, the ISP begin date will be the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
- for a member who did receive continued benefits, the ISP begin date will be the first day of the month following the termination date;
mail Form H2065-D to the member;
ensure the ISP is updated in SASO with the correct effective dates by following the instructions in Section 9000;
for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
- a subject line that reads: Reversed Program Hearing Decision - STAR+PLUS HCBS Program - Appeal – XX [first letter of the member’s first and last name];
- the member’s name;
- Medicaid ID number;
- HHSC Benefits portal Appeal ID number;
- TIERS case number;
- ISP receipt date;
- ISP begin date;
- ISP end date;
- TIERS Medicaid eligibility effective date;
- TIERS managed care effective date;
- Form H2065-D; and
- the state fair hearing decision;
for MAO members, notify CRU staff by email at the HHSC AES Fair Hearings mailbox. The email to CRU staff must include:
- a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the member’s first and last name];
- the member’s name;
- Medicaid ID number;
- type of request (i.e., continue or reinstate Medicaid eligibility);
- type of service (i.e., STAR+PLUS HCBS program);
- HHSC Benefits portal Appeal ID number;
- TIERS case number;
- TIERS Medicaid eligibility effective date;
- Form H1746-A;
- Form H2065-D; and
- the state fair hearing decision;
upload all applicable documents to the HEART case record following the instructions in Appendix XXXIII; and
document and close the HEART case record.

7421 Reversed Decision – Effective Date

Revision 19-13; Effective November 5, 2019

When the hearings officer’s decision reverses the denial of STAR+PLUS Home and Community Based Services (HCBS) program eligibility, the effective date Program Support Unit (PSU) staff enter on Form H2065-D, Notification of Managed Care Program Services is:

for applicants, the first of the month following the hearings officer’s decision; or
for members at reassessment, one day after the end of the individual service plan (ISP) in effect when the state fair hearing was filed.

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 B of 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 Centralized Representative Unit (CRU).

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

7422 New Assessment Required by State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

If the hearings officer’s decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Medical Necessity and Level of Care (MN/LOC) Assessment, or Form H6516, Community First Choice Assessment, the state fair hearing is closed, pending the results of the new assessment. Program Support Unit (PSU) staff must notify the applicant, member or authorized representative (AR) 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 AR may appeal the results of the new assessment. If the applicant, member or AR chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, on Form 4800-D, 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 AR 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 STAR+PLUS Home and Community Based Services (HCBS) program 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/LOC Assessment, which results in another MN denial. PSU staff send a notice to the member or AR informing him or her of the MN denial. The member or AR then requests 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 AR 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.

7423 Request to Withdraw a State Fair Hearing

Revision 19-13; Effective November 5, 2019

An applicant, member or authorized representative (AR) 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 AR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or AR 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 AR 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 AR and must be made to the hearings officer.

If the applicant, member or AR 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 AR 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.

STAR+PLUS Program Support Unit Operational Procedures Handbook