Revision 23-1; Effective July 31, 2023

1410 Right to a Fair Hearing - 1 TAC Sections 357.3, 357.7, and 357.19(b)(3)

Revision 23-1; Effective July 31, 2023

What Can be Appealed

Clients of Medicaid-funded services, TANF, SNAP and other agency programs in which state or federal law or rules provide a right to a fair hearing, are entitled to appeal the following actions:

• an action to reduce, suspend, terminate or deny benefits or eligibility;
• a failure to act with reasonable promptness on a client's claim for benefits or services;
• a decision to transfer or discharge a resident from a skilled nursing facility or nursing facility;
• an adverse determination made regarding Preadmission Screening and Resident Review;
• the denial of a prior authorization request;
• the failure to receive a service authorization request; 
• the failure to reach a service authorization decision within the period specified by federal law; and 
• an action taken to recoup benefits previously paid to a recipient.

A client may appeal more than one action at the same time, in writing or orally, unless specified in program rules or notices.

Exceptions:

• A SNAP household can contest the SNAP benefit amount by requesting a fair hearing when it is aggrieved by a mass change in benefits.
• A client may appeal the application to him of an across-the-board reduction in benefits or services on the grounds that the mass change does not apply to him.
• Under all programs, the agency is not required to grant a hearing if the sole issue is a federal or state law requiring an automatic mass change adversely affecting some or all clients. This may be determined at a pre-hearing conference.

What Cannot be Appealed

The hearings officer does not have jurisdiction when the repayment of an overpayment is court-ordered. The hearings officer will schedule a pre-hearing conference to review documents supporting a claim that the repayment is court-ordered.

Issues related to non-payment of a claim to a provider are not appealable.

Note: HHS agency staff may not prevent a client from filing an appeal because staff believe that the item, service or benefit is not subject to appeal. The hearings officer determines if an issue is appealable.

1420 Period for Requesting a Fair Hearing - 1 TAC Sections 357.3 and 357.7

Revision 23-1; Effective July 31, 2023

The appellant has a right to file an appeal within 90 calendar days from the effective date of the action or from the notice of adverse action date, whichever is later. 

Exceptions: 

• Pursuant to 7 CFR Section 273.15(g), a client may appeal their current level of SNAP benefits at any time during a certification period. A SNAP client may also appeal the denial of a request to restore benefits that were lost within one year prior to the request.
• According to program rules at 1 TAC Section 386.408, a participant in the Disaster Assistance program has 60 days from the date on the reconsideration decision letter to request a fair hearing.
• On overpayment claims, a client must file an appeal within 90 days of the date the overpayment claim was sent.
• For MCO-related appeals, appellants have 120 days from the date of the MCO’s final determination, to request a fair hearing.

Note: HHS agency staff may not prevent a client from filing an appeal because staff believe that the appeal was not requested within the required number of calendar days. The hearings officer is the final authority regarding the timeliness of filed appeals and may accept appeals filed after the time limit to determine whether there was good cause for the delay in filing.

If a request for a hearing is not received within the required time frame, and the hearings officer determines good cause was not established for the failure to file timely, the individual has forfeited the right to a fair hearing and the agency action becomes final.

1430 Determining Good Cause for Appealing Past 90-Day Time Frame

Revision 23-1; Effective July 31, 2023

If an appellant appeals after the 90-day time frame, the hearings officer must determine if the appellant had good cause for failing to appeal timely.

The hearings officer may schedule a pre-hearing conference or schedule a regular hearing and determine good cause at the beginning of the hearing.

Exception: If the hearings officer receives a request for an over payment claim hearing past the 90-day time frame, a pre-hearing conference will be scheduled to determine good cause for the appellant's failure to request the fair hearing in a timely manner.

1440 Creating and Submitting a Fair Hearing Request - 1 TAC Section 357.7

Revision 23-1; Effective July 31, 2023

The agency must accept a request for a fair hearing for one or more actions and create an appeal in the TIERS Hearings and Appeals module. The request must be created and submitted in TIERS within five calendar days from the date the fair hearing was requested. This includes requests made after the 90-day time frame. 

Example: If the client requests a fair hearing on Tuesday, the 5th calendar day is Sunday. Agency staff need to submit the request no later than close of business on Friday.

1450 Continued Benefits - 1 TAC Section 357.11

Revision 23-1; Effective July 31, 2023

After an HHSC agency or designee takes an action that affects a client’s benefits or services, the client is entitled to receive, under certain circumstances, continued benefits or services until a hearing decision is issued. Whether a client is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program.