Revision 10-1; Effective January 15, 2010
Fair hearing activities are based on federal and state statutes, rules and regulations. Statutes provide an outline of all requirements, while the rules and regulations provide more detail on how to apply the statute.
1110 Federal Statutes and Regulations
Revision 10-1; Effective January 15, 2010
- §1396a of the Social Security Code relates to Medicaid requirements in the State Plan.
- Title 7, USCA §2020(e)(10) relates to Supplemental Nutrition Assistance Program (SNAP) requirements.
- Regulations concerning fair hearings for Temporary Assistance for Needy Families (TANF) are in 45 CFR §205.10.
- Regulations concerning fair hearings for Medicaid are in 42 CFR §431.205.
- Regulations concerning fair hearings for SNAP assistance are in 7 CFR §273.15.
1120 Texas Laws
Revision 10-1; Effective January 15, 2010
1121 Financial, Medical and Social Service Assistance
Revision 10-1; Effective January 15, 2010
- §31.034 of the Texas Human Resources Code provides the right to appeal to an applicant for or recipient of financial assistance in TANF.
- §32.035 of the Texas Human Resources Code makes the provisions of §31.034 applicable to applicants for medical assistance.
- §12.001 of the Texas Human Resources Code prohibits a person who is not licensed to practice law in Texas from charging a fee for representing an applicant or recipient in procuring services.
1130 Texas Rule and Regulation Authority
Revision 10-1; Effective January 15, 2010
1131 Authority and the Right to Appeal — 1 Texas Administrative Code (TAC) §357.3(a)(1)
Revision 11-4; Effective June 1, 2011
The Health and Human Services Commission (HHSC) is authorized by law to adopt and implement rules to administer the programs it oversees. These uniform fair hearing rules apply to the TANF program, SNAP (formerly the Food Stamp Program), all Medicaid-funded services and all other agency programs that are required by state or federal law or rules to provide the right to a fair hearing. HHSC delegates to the Appeals Division the authority to appoint hearings officers and to hear fair hearings.
HHSC Appeals Division is responsible for publishing fair hearing rules; processing fair hearing appeal requests; conducting fair hearings and issuing decisions.
1140 Definitions — 1 TAC §357.1
Revision 11-4; Effective June 1, 2011
The following words and phrases, when used in this handbook, have the following meanings unless the context clearly indicates otherwise.
- Across the Board Reduction of Services – Benefits may be terminated or reduced as the result of a change in Federal or State regulations adversely affecting some or all recipients.
- Action Effective Date – The date the agency action becomes effective.
- Adequate Notice – Notice in accordance with applicable law, rules and regulations of the programs.
- Agency – Any one of the agencies listed under the Health and Human Services (HHS) agencies.
- Agency Action – The action taken by the agency on an applicant or recipient's request for services.
- Agency Representative – An individual from an agency or its designee who is authorized to represent the agency or its designee in a fair hearing.
- Appeal – A request for a review of an agency action or failure to act that may result in a fair hearing.
- Appellant – A client who requests a fair hearing.
- Authorized Representative – A person designated by the appellant in writing or designated by statute, regulation or rule or named by the appellant on the record who may act on behalf of the appellant at the fair hearing.
- Benefit – A service administered or assistance provided by the agencies or their designees, including determining eligibility for services in the SNAP, TANF and Medicaid-funded programs, and other agency programs in which state or federal law or rules provide a client the right to a fair hearing.
- CRU – Centralized Representation Unit within the HHSC Office of Eligibility Services processes appeal requests, appears at hearings, and implements hearing decisions.
- Certified Spanish/English Interpreter – An interpreter who is certified by one of the following entities:
- American Translators Association;
- Federally Certified Court Interpreter through the Federal Court Interpreter Certification Examination;
- Interpreter Certification offered through a four-year college or university;
- State Certification Programs;
- U.S. Department of State (Escort, Seminar or Conference level); or
- Any other nationally recognized certification program.
- CFR – Code of Federal Regulations.
- Client – A person who applies for or receives benefits from one of the HHS agencies.
- Date of Appeal Request – The date on which the appellant or the appellant's authorized representative clearly expresses, in writing or orally as required, a desire to appeal.
- Date of Decision – The date of the hearings officer's decision, as noted on the decision document.
- Date of Notice of Agency Action – The date on the written notice informing the client of the agency action.
- Day – Calendar day, unless otherwise specified.
- Designee – A contractor, employee or other agent designated to act for an agency.
- Fair Hearing – An informal proceeding held before an impartial HHSC hearings officer in which a client appeals an agency action. These hearings are not open to the public.
- Good Cause – The failure to appear for a hearing as a result of circumstances the person could not control.
- Health and Human Services (HHS) Agencies:
- Health and Human Services Commission (HHSC);
- Department of Aging and Disability Services (DADS);
- Department of Assistive and Rehabilitative Services (DARS);
- Department of Family and Protective Services (DFPS);
- Department of State Health Services (DSHS); and
- A reference to an agency includes a designee.
- Health Plan – Includes managed care organizations (MCOs) and primary care case management (PCCM) plans.
- Hearings Administrator – The administrator for fair and fraud hearings in the HHSC Appeals Division who oversees daily operations and staff conducting fair hearings.
- Hearings Officer – An HHSC employee designated by the director of the Appeals Division who is responsible for conducting fair hearings and issuing decisions.
- Integrated Care Management (ICM) Program – A Medicaid managed care plan where an ICM contractor manages and coordinates acute care services and long-term services and supports for eligible Medicaid clients.
- Language Services – Any services that ensure effective communication for full participation of all parties in a hearing.
- Managed Care Organization (MCO) – An entity that has a current Texas Department of Insurance certificate of authority to operate as a health maintenance organization (HMO) or as an approved nonprofit health corporation under the Texas Insurance Code.
- MOR – Managed Office Resources is the reporting structure in the TIERS application.
- Nursing Home Action – The nursing home's decision to transfer or discharge a client.
- OES – Office of Eligibility Services.
- Party – An appellant or his authorized representative or an agency or its representative.
- PASARR – Pre-Admission Screening Annual Resident Review Determination.
- Pre-hearing Conference – An informal conference that is scheduled by the hearings officer to resolve issues of procedure, jurisdiction or representation, or to clarify other issues prior to the fair hearing.
- Preponderance – The greater weight of the evidence required in a civil lawsuit for the trier of fact to decide in favor of one side or the other. This preponderance is based on the more convincing evidence and its probable truth or accuracy, and not on the amount of evidence.
- Primary Care Case Management (PCCM) – A managed care model allowed under federal regulations in which the Commission contracts with providers to form a managed care provider network.
- Person with Limited English Language Proficiency (LEP) – Person who does not speak English as a primary language and who has a limited ability to read, speak, write or understand English.
- Prior Authorization Request – A request for services that is reimbursable only if authorization or approval for the services is obtained before services are rendered.
- SNAP – Supplemental Nutrition Assistance Program, formerly known as Food Stamps.
- TANF – Temporary Assistance for Needy Families.
- Texas Health Steps (THSteps) – A program under Medicaid that provides medical and dental check-ups, diagnosis and treatment to eligible clients from birth through age 20. THSteps was formerly known as Early and Periodic Screening, Diagnosis and Treatment (EPSDT).