2900, Appeals and Fair Hearings

2910 Individual’s Right to Appeal and Request a Fair Hearing

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903

(a) An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits.
(b) A client is entitled to be notified 10 days before any reduction or termination of his services, or to have the notification mailed 12 days before the date of reduction or termination. If a client threatens his own health or safety or that of others, purchased services may be terminated without advance notice.

Inform the applicant/individual in writing by sending Form 2065-A, Notification of Community Care Services, about his right to request a fair hearing if services are denied, reduced or terminated. An individual may appeal his dissatisfaction concerning

  • ineligibility for services;
  • the tasks within a service;
  • the amount (number of units) of service the individual will receive;
  • the amount of the copayment for Residential Care; or
  • the denial or termination of the priority status.

An individual also may appeal when the individual requests a new service, or requests an increase in the number of tasks or units of service, and the request is not acted on within required time limits.

To request a hearing, an individual may return Form 2065-A with a check mark in the appropriate box, or the individual may make an oral or written request for a fair hearing.

An individual must request a fair hearing within 90 days from the date of the action he wants to appeal. To continue receiving benefits until the hearings officer gives a decision, the individual must request the fair hearing before the effective date shown on Page 1 of Form 2065-A. In situations where services were terminated because of threats to the health or safety of another person, the individual is not entitled to continued services even if appealed before the effective date shown on Page 1 of Form 2065-A. (See Section 2811, Effective Dates, and Appendix IX, Notification/Effective Date of Decision, for guidance on effective date of termination in which the individual is not entitled to continued benefits.)

When a fair hearing is requested after the 90 day time period, HHSC staff may not prevent an applicant or individual from filing an appeal because they believe the appeal was not requested within the required number of days. If a fair hearing request is received after 90 days from the date of the notice, the case worker must follow current procedures to file the appeal. The hearings office will make the decision regarding the individual’s right to appeal.

The hearings officer is the final authority regarding the timeliness of appeal requests and accepts appeals filed after the time limit in order to determine whether there was good cause for the delay in filing.

 

2911 Notice to the Provider for Continuing Services

Revision 17-1; Effective March 15, 2017

If the individual appeals before the effective date on Page 1 of Form 2065-A, Notification of Community Care Services, the case worker must continue services at the current level pending the hearings officer’s decision, unless denial is based on threats to health and safety. (See Section 2840, Threats to Health and Safety). Within three business days after receipt of the request for a fair hearing, the case worker must complete a new Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO) reinstating services at the current level. The case worker sends Form 2101 to the provider notifying them to provide services at the current level until the hearings officer’s decision is rendered. The “Begin Date” of services is the day after the termination date or reduction date on the previous Form 2101. The case worker also sends Form 2067, Case Information, informing the provider to reinstate services pending the hearings officer’s decision.

Example 1: At the annual reassessment, the case worker determines the Primary Home Care personal attendant services (PAS) hours must be reduced from 20 hours per week to 15 hours per week. The case worker sends Form 2065-A to the individual and Form 2101 to the Home and Community Support Services Agency (HCSSA) as notification of the reduction in hours. The individual appeals before the effective date of the case action. The case worker authorizes PAS at 20 hours per week until the hearings officer’s decision is rendered.

When all services are terminated, such as at the annual reassessment when the individual does not meet eligibility criteria, case workers must continue services at the current level when the individual files an appeal before the effective date.

Example 2: At the annual reassessment, a Family Care individual is terminated due to scoring 21 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The case worker sends Form 2065-A to the individual and Form 2101 to the provider as notification of the termination of services. The individual appeals before the effective date of the case action. The case worker authorizes services at the same level as the previous Form 2101 authorization.

When the individual submits a clear, written statement requesting services stop during the appeal process, the case worker sends Form 2067 to the provider with an effective date to stop service delivery. The case worker does not send the individual another Form 2065-A.

HHSC does not continue services during the appeal process if Medicaid eligibility has been terminated, unless Medicaid eligibility is reinstated during the appeal period. Refer to Section 3441, Loss of Categorical Status or Financial Eligibility, and Section 2932, Coordination of Fair Hearings with MEPD Utilizing OES CRU, for procedures related to Medicaid terminations and continuation of services.

 

2912 Special Procedures for Denials of Community Attendant Services (CAS) Individuals

Revision 17-1; Effective March 15, 2017

Denials of CAS individuals must be coordinated with both the HHSC regional nurse and with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. If the HHSC case worker denies the individual based on functional need, Form H1746-A, MEPD Referral Cover Sheet, must be sent to advise MEPD of the denial.

If the individual appeals the denial, another Form H1746-A must be sent to MEPD advising that services will be reinstated pending the fair hearings officer’s decision. MEPD must also be notified on Form H1746-A when a decision is rendered.

If the change that prompted the request for an appeal on a Community Attendant Services decision occurred in the course of an annual reassessment, use Form 2067, Case Information, to notify the provider and the HHSC regional nurse. The HHSC regional nurse submits Form 2101, Authorization for Community Care Services, to reinstate services.

 

2913 Coordinating with Utilization Review for Fair Hearing Requests as a Result of Utilization Review Findings

Revision 17-1; Effective March 15, 2017

HHSC case workers must notify the utilization review (UR) nurse and UR regional manager when an applicant or individual has requested a fair hearing as a result of UR findings for concurrent reviews.

Case workers must follow normal time frames and procedures for implementing UR findings following receipt of a UR tool indicating a case action is required. When the action is completed for an addition/increase in services or termination/decrease in services, the case worker must send a notice to the applicant or individual notifying him of the case action. The applicant or individual has the option to appeal the case action indicated on the notice. Case workers must follow current policies and procedures regarding continuation of services pending an appeal.

If the applicant or individual requests a fair hearing, the case worker must inform the UR nurse who completed the review and UR regional manager via email that a fair hearing has been requested as a result of the UR findings. The case worker will complete Form H4800, HHSC Fair Hearing Request Summary, and send the form to the Hearing Division and supervisor within three days of the request for a hearing.

On Form H4800, the case worker will list the UR nurse, Agency Representative, UR regional manager, and Agency Representative Supervisor. The case worker may be listed. The case worker must confirm the correct UR nurse and UR regional manager to list on the form. The case worker includes the UR nurse whose name is located in Section A of the UR tool. The case worker identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The designated data entry representative (DER) will be responsible for uploading the case worker’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system. The evidence packet submitted by the case worker will include the applicable notification form. If available, the case worker includes the signed notification form returned by the applicant or individual. The case worker does not include any other documentation in the evidence packet.

The UR nurse and UR regional manager will develop the fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or individual. The evidence packet will include a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the evidence packet in TIERS.

Form H4800-A, Fair Hearing Request Summary (Addendum), must be included as the cover sheet for each fair hearing evidence packet. The DER and UR representative must upload the fair hearing evidence packets in TIERS no later than 10 calendar days prior to the fair hearing date. The case worker and UR nurse must forward a copy of the fair hearing evidence packets to the applicant or individual no later than 10 calendar days prior to the fair hearing date.

The UR nurse, UR regional manager (optional) and case worker will participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony regarding the case action.

 

2913.1 Concurrent Utilization Review When a Fair Hearing is Pending or a Decision Has Been Rendered

Revision 17-1; Effective March 15, 2017

When a case record is selected for concurrent review and a fair hearing is pending, the case worker must inform the Utilization Review (UR) nurse that a fair hearing is pending. The case worker does not submit the case record for concurrent review. UR will then replace the case with another randomly selected case record for concurrent review.

When a case record is selected for concurrent review and a fair hearing decision has been rendered during the current plan year, the case worker must inform the UR nurse of the fair hearing decision details by providing the UR nurse with a copy of the final order submitted by the hearings officer. The case worker must provide specific information to the UR nurse about the service(s) appealed and the actions the case worker took to implement the hearings officer’s decision. The case worker submits the case record for concurrent review following current procedures. The case worker will follow current policy and procedures for implementing UR findings.

 

2914 Withdrawal of an Appeal

Revision 17-1; Effective March 15, 2017

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. HHSC staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts HHSC staff regarding the withdrawal, HHSC staff must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to HHSC staff, HHSC staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on an HHSC decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify HHSC by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw his appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and a written notice will be sent to participants informing them of the fair hearing cancellation.

 

2920 Request for Increase in Services During an Appeal

Revision 17-1; Effective March 15, 2017

 

When services are reduced or terminated, such as at the annual reassessment, and the individual files an appeal before the effective date of the reduction or termination, the case worker must continue services at the current level until the hearings officer’s decision is rendered. If the individual requests increased services pending the hearings officer’s decision, the case worker cannot process the request. Within 14 calendar days of the request, the case worker must send the individual Form 2065-A, Notification of Community Care Services, explaining the request for increased services is denied pending the hearings officer’s decision and may be reviewed for authorization once the hearings officer’s decision is rendered, if the individual is determined eligible.

 

2930 Fair Hearing Procedures

Revision 17-1; Effective March 15, 2017

All fair hearings are processed through the Fair and Fraud Hearings section of the Appeals Division of the Texas Health and Human Services Commission (HHSC). The appeals division receives appeal requests from applicants and individuals contesting actions taken regarding benefits and services of various programs. These include the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp Program), Temporary Assistance for Needy Families, all Medicaid-funded services, and other agency programs that are required by state or federal law, or rules, to provide the right to a fair hearing. Hearings officers conduct hearings, consider evidence and issue decisions in accordance with rules, regulations and state and federal law.

See the HHSC Fair and Fraud Hearings Handbook for specific information regarding the HHSC rules and requirements governing the fair hearings process.

 

2931 Processing Fair Hearing Requests Using TIERS

Revision 17-1; Effective March 15, 2017

When a request for a fair hearing is received from an applicant or individual orally or in writing, the Texas Health and Human Services Commission (HHSC) must refer the request to the hearings officer within five calendar days from the date of the request. Information is not mailed to the hearings officer, but is entered into the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system by the designated data entry representative.

Upon receipt of the fair hearing request, the case worker completes Form H4800,  Fair Hearing Request Summary.

The case worker sends Form H4800 to the Hearing Division and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the data entry representative two days to enter the information into the TIERS system. See the Form H4800 Instructions for specific directions for completion and transmittal.

Designated Data Entry Representative Procedures

Within two calendar days of receipt of Form H4800, the data entry representative enters the information into the Fair Hearings and Appeals system in TIERS. When the entry of all the information is completed, the system assigns the appeal identification (ID) number. The data entry representative will note the appeal ID number on the bottom of the form and in the designated space on the front of the form and send a copy back to the case worker and supervisor.

HHSC Fair Hearings and Appeals Procedures

The TIERS system will generate a hearing packet which includes Form H4803, Notice of Hearing, and Form H4800. The case worker and supervisor will receive a copy of Form H4800 and the letter identifying the hearings officer assigned and information on the time and location for the hearing. It is the supervisor's responsibility to ensure that the case worker or a designated representative participates in the hearing and is sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

If Form H4800 has already been submitted into TIERS and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for a fair hearing, the case worker completes Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submits it to the data entry representative.

The data entry representative must check TIERS for the fair hearings officer assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information. When sending information, the data entry representative completes the following activities according to the situation:

  • When Form H4800-A is completed informing the fair hearings officer of address changes, participant updates and withdrawal forms, the data entry representative sends Form H4800-A directly to the hearings officer’s email address. The case worker must enter the appeal ID number in the subject line.
  • When the data entry representative submits supporting documentation for an appeal, he uploads the information directly into TIERS and sends the hearings officer an email with Form H4800-A attached. The case worker must enter the appeal ID number in the subject line. The email must also inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded in TIERS. The case worker and data entry representative must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

 

2932 Coordination of Fair Hearings with MEPD Utilizing OES CRU

Revision 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) Centralized Representation Unit (CRU) handles all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works staff. CRU replaces the MEPD specialist in specific steps related to denial of MEPD applications and ongoing cases. CRU:

  • represents HHSC OES in fair hearings;
  • completes and implements all MEPD case actions based on fair hearing decisions; and
  • coordinates actions required with regional MEPD staff and HHSC staff.

The case worker must coordinate all appeals with CRU in which MEPD staff determine financial eligibility. The case worker must remember CRU replaces the local MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and CRU administrative assistant.

Applicants/individuals may appeal a decision orally, in person or in writing. The case worker is responsible for completing Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/individual requests a fair hearing. The method in which the form is completed depends on the action being appealed. HHSC staff must determine if the appealed action is:

  • a waiver/service denial (excludes denials based on MEPD denials); or
  • an MEPD financial denial (denials based on an MEPD denial action).

If the appealed action is related to Community Care Services Eligibility (CCSE) criteria other than an MEPD financial denial action, the case worker completes Form H4800 and enters his name as the "Agency Representative." In the "Additional Witnesses” field, HHSC staff enter "CRU Supervisor" (enter the actual name), and "CRU Administrative Assistant" (enter the actual name). The CRU supervisor and administrative assistant names must be entered by using the "MOR Search" function. This will ensure that all the correct information is populated in TIERS and both the CRU supervisor and the administrative assistant receive the notice of the appeal.

If the appealed action is an MEPD financial denial, the case worker completes Form H4800 and enters "CRU Supervisor" (enter the actual name) as the "Agency Representative." This information must be entered through the "MOR Search" function for CRU to receive the hearing information. List the HHSC case worker, supervisor and titles in the "Additional Witnesses” section. The name of the local MEPD specialist is not entered by staff on Form H4800 for MEPD financial appeals. HHSC staff must include the title, such as HHSC case worker or HHSC supervisor. Enter the HHSC staff email address. Enter the CRU administrative assistant (enter the actual name) in "Additional Witnesses” using the "MOR Search" function.

When Form H4800 is sent to the Hearing Division, the case worker sends an email notification regarding the request for an appeal to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, oesfairhear@hhsc.state.tx.us. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID-XXXXXXX. In an attachment to the email, HHSC staff must also include a copy of the HHSC notification form sent to the applicant or individual. The email must include the:

  • applicant's/individual's name;
  • Medicaid number (if available);
  • type of service (CCSE Community Attendant Services); and
  • specific information requesting the MEPD financial case remain active/open during the appeal, if the applicant/individual appealed in a timely manner.

For example, the financial case or application may need to remain open pending an appeal decision regarding medical or functional eligibility. The case worker must notify CRU to keep the MEPD case open pending the fair hearing decision.

Upon receipt of notification of an appeal, CRU requests the MEPD evidence packet from the local MEPD specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent MEPD at the hearing, if required, and takes steps to ensure the appropriate MEPD financial case action is taken once a hearings officer's decision is rendered.

When a hearing decision based on program criteria is rendered by the hearings officer, the case worker (staff name entered as "Agency Representative") will be notified via email of the decision by the hearings officer. Based on the hearing decision, the case worker determines the appropriate action according to program specific time frames. The case worker may need to coordinate effective dates of reinstatement with CRU and must email the CRU supervisor and administrative assistant for the coordination. The case worker reports the implementation of the hearing decision through TIERS on Form H4807, Action Taken on Hearing Decision, according to current procedures.

The local MEPD specialist will continue to notify the case worker if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to CRU to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU will notify HHSC staff via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, the case worker determines the appropriate action for the service. The email sent by CRU will include:

  • the applicant's/individual's name;
  • Medicaid number;
  • a copy of the hearing decision; and
  • effective or denial date of Medicaid eligibility.

The case worker must not put an applicant/individual back on a specific interest list while an MEPD denial is in the appeal process. The case worker must take appropriate action to certify or deny the case, or resume services once the MEPD hearing decision is rendered. The individual may choose to be added back to the interest list once the case worker denies the service.

 

2933 Submitting the Appeals Evidence Packet

Revision 17-1; Effective March 15, 2017

When an applicant or individual requests a fair hearing, the burden of proof to uphold the Texas Health and Human Services Commission (HHSC) decision rests with HHSC. The hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency decision.

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The case worker and his/her supervisor receive a copy of Form H4800 and the letter identifying the hearings officer assigned, and the time and location of the hearing. Staff or the designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

Each entity involved in the fair hearing is responsible for preparing its packet and forwarding the packet to both the:

  • hearings officer identified on Form H4800; and
  • appellant.

All documentation must be neatly and logically organized, and all pages numbered. Staff use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

Provide the names, titles, addresses and telephone numbers of all persons or designees who will attend the hearing. Depending on the issue being appealed, the region may elect to send additional staff (e.g., the regional nurse, regional attorney, etc.); however, it is mandatory that the following staff attend:

  • Texas Medicaid & Healthcare Partnership (TMHP), for medical necessity/level of care (MN/LOC) denials;
  • Medicaid for the Elderly and People with Disabilities (MEPD) or Centralized Representation Unit (CRU), for financial denials;
  • case worker or designee, for all case decisions; and/or
  • Utilization Review nurse to the appeal action, if applicable.

All related documentation necessary to support the agency's decision must be sent by the data entry representative (DER) to the fair hearings officer as soon as possible, but no later than 10 calendar days before the hearing. Examples of additional information and who is responsible for submitting that information to the state fair hearings officer and appellant include, but are not exclusively limited to:

  • the case worker or designee:
    • Texas Administrative Code or policy handbook references related to the case action;
    • summary of events;
    • a copy of any individual service plans, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or other official documentation forms including form instructions;
    • other documentation supportive of the decision, such as records of telephone calls, visit summaries, etc.;
    • any relevant Utilization Review findings; and
    • a signed copy of the denial notification form (if available, use the signed form returned by the applicant/individual when the appeal was filed);
  • MEPD:
    • documentation supportive of the financial decision, including official documentation forms, telephone calls, etc.; and
    • a copy of the original signed denial form returned by the member, if available (if unavailable, send unsigned copy);
  • TMHP:
    • a copy of the MN/LOC assessment; and
    • other documentation supporting the decision.

Uploading the Appeals Evidence Packet into TIERS

All evidence packets must be scanned into the TIERS Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A to submit all supporting documentation (also referred to as the "appeals packet") to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A. The DER must upload the fair hearing evidence packet in TIERS no later than 10 calendar days prior to the fair hearing date.

The case worker must provide the information to the DER no later than 12 calendar days prior to the fair hearing date, to allow enough time for the evidence packet to be submitted timely. The case worker must:

  • go to the multi-function HHSC WorkCenter and scan in the documentation;
  • save the document by either allowing the default document name or entering a name of the user's choosing;
  • retrieve the scanned document and attach it to an email; and
  • send the document to the regional DER.

No later than 10 calendar days prior to the fair hearing date, the case worker must forward a copy of the fair hearing evidence packet to the applicant or individual requesting the fair hearing.

Within two business days after receipt, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the TIERS portal (without launching TIERS) and select the "Appeals" tab;
  • ensure the appeal has been entered in TIERS (this requirement must be met before the next step can be completed);
  • select "Hearing Evidence Packets Upload" and enter the appeal identification;
  • 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; and
  • select "Upload."

Users who make mistakes that cannot be reversed may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

 

2934 Presentation of Evidence at the Fair Hearing

Revision 17-1; Effective March 15, 2017

Staff listed on Form H4800, Fair Hearing Request Summary, will receive Form H4803, Notice of Hearing, notifying participants when the hearing will be held. HHSC staff must adequately prepare both the fair hearing packet and presentation of evidence at the fair hearing. The burden of proof to uphold the agency's decision rests with the agency. The hearings officer is a neutral party and is restricted by law from presenting the agency's case.

Documentation contained in the fair hearing packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Joe Smith. Pages 1-10 contain information relating to the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the Community Care for Aged and Disabled Handbook, which relate directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form 2065-A, Notification of Community Care Services, which was mailed to the applicant on March 2, 2010."

The hearings officer usually can only consider the specific information offered in evidence when making the hearing decision. For example, the case worker may clearly explain how the applicant must score 24 points on Form 2060 to be eligible for Primary Home Care. However, if documentation backing up that explanation (Handbook policy, Form 2060 Instructions and appropriate appendices) is not contained in the packet, the explanation will not be considered.

Oral testimony may be considered only if read into the record and if the appellant agrees to allow it.

The hearings officer will ask the appellant if he received the evidence packet. If not, the hearings officer will attempt to determine why. If no effort was made to send a packet to the appellant, the packet may not be admitted and the appropriate agency representative will have to read information into the record in order to have it considered.

The hearings officer will then ask for objections and allow all admissible documents into evidence. Any documents admitted by the hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case has been clearly presented. If any documents are not admitted, the hearings officer will explain the reasons for excluding the material.

 

2935 Action Taken after the Hearing Decision

Revision 17-1; Effective March 15, 2017

 

2935.1 Action Taken on the Hearing Decision for Reductions

Revision 17-1; Effective March 15, 2017

After the hearing is held, the Texas Health and Human Services Commission (HHSC) hearings officer will send a decision letter, Form H4807, Action Taken on Hearing Decision, to the appellant and send copies to the case worker and the supervisor. If the HHSC decision is sustained, then the case worker takes the appropriate action. If services continued during the appeal period, then the case worker completes a new Form 2101, Authorization for Community Care Services, and sends it to the provider with the reduced service amounts. The action must be completed within 10 calendar days after the hearings officer’s decision. It is not necessary to send the individual another Form 2065-A, Notification of Community Care Services, since the individual has already been notified of the change.

If the hearings officer reverses the decision, the hearings officer also sends HHSC Form H4807 and specifies the corrective action to be taken and a 10-day time frame for the completion of the action. The case worker continues authorization at the higher level of services. The case worker sends the individual Form 2065-A showing the new level of services. A new Form 2101 is not required, since the provider is already delivering services at the higher level. The case worker actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Form H4807 is no longer completed and mailed back to the hearings officer. All communication will be through TIERS.

 

2935.2 Action Taken after the Hearing Decision of Terminations

Revision 17-1; Effective March 15, 2017

Once the hearings officer’s decision is rendered and if the individual is determined eligible to continue receiving services, the case worker sends Form 2065-A, Notification of Community Care Services, to the individual to notify him that the hearings officer’s decision overturned the termination and his eligibility is continued. The case worker includes the following statement in the comments: “The hearings officer has overturned the termination decision and you have been determined eligible for continued services effective (the begin date).” The case worker sends the provider an updated Form 2101, Authorization of Community Care Services, reinstating services.

If the hearings officer sustains the termination decision and services were not continued, then no further case worker action is required on the case. If the hearings officer sustains the termination decision and services were continued, the case worker must terminate services in Service Authorization System and send the provider Form 2101 ending services within 10 calendar days after the hearings officer decision, or in accordance with instructions provided by the hearings officer. The case worker does not send another Form 2065-A to the individual to provide notification that the individual is not eligible based on the hearings officer’s decision. The case worker orally notifies the individual of the termination of services and the effective date and documents the contact in the case record.

 

2935.3 Fair Hearings Officer Orders a New Assessment

Revision 17-1; Effective March 15, 2017

If the hearings officer’s final decision orders completion of a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the hearing is closed as a result of this ruling. The case worker must notify the individual of the results of the new assessment on Form 2065-A, Notification of Community Care Services. The individual may appeal the results of the new assessment. If the individual chooses to appeal, the case worker must indicate in Section 8, Summary of Agency Action of Form H4800, HHSC Action Taken on Hearing Decision, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision. If the individual requests an appeal of the new assessment, HHSC continues services until the second fair hearing decision is implemented.

 

2935.4 Reporting the Action Through TIERS

Revision 17-1; Effective March 15, 2017

The case worker completes Form H4807, Action Taken on Hearing Decision, recording case actions taken and sends it to the supervisor and the designated data entry representative. The case worker must send Form H4807 within the time frames to allow at least two days for the data entry representative to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, the case worker must complete Section B on Form H4807 and send to the supervisor and data entry representative providing the reason for the delay. Acceptable reasons are listed on the form and the begin delay date and end delay date must be included. See the form instructions for detailed information on completing Form H4807.

 

2936 Fair Hearing Exception Process

Revision 17-1; Effective March 15, 2017

When a fair hearing decision is rendered, staff must implement the decision of the fair hearings officer within the applicable time frames, including the restoration of any benefits or services.

Staff who disagree with the result of a fair hearing must follow regional procedures in referring the issue to the regional director. Staff use Form 1590, Request for a Fair Hearing Exception, to initiate a fair hearing exception request. The form documents the region's request for a review of a fair hearing decision.

If he agrees with the region's request, the regional director forwards Form 1590 to the Community Services Policy (CSP) unit manager. The CSP unit manager must receive the form by the fifth calendar day following the date on the hearing decision. A copy of the form is kept in regional files, not in the case record.

Upon reviewing the region's exception request, the CSP unit manager will decide whether to forward the exception request for consideration by HHSC. If the CSP unit manager (or designee):

  • concurs with the regional assertion that policy was misapplied, the form is forwarded to the Fair and Fraud Hearings Section.
  • determines a clear error of law or fact was made by the hearings officer, he requests that HHSC review the case action and, if they are in agreement, issues a revised hearing decision.
  • does not concur with the regional request, the request will not be forwarded to HHSC.

If the CSP unit manager forwards the exception request for consideration by HHSC, then the HHSC case worker or designee must mail Form 1015 or Form 1015-S, Fair Hearing Exception Letter, and a copy of the exception request to the applicant or individual. The case worker or designee must place the letter and exception request in the outgoing mail by the close of the next business day following receipt of the notification from the CSP unit manager. A copy of the letter and exception request must be placed in the case record.

The region will be notified of the decision whether the request was or was not forwarded to HHSC. Even if an exception request is being filed, the hearings officer's decision must be implemented within the required time frames.