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Revision 22-3; Effective Dec. 1, 2022
If an applicant, member, or legally authorized representative (LAR) wishes to request a State Fair Hearing with the state of Texas regarding a Medically Dependent Children Program (MDCP) waiver eligibility denial, they must contact the Program Support Unit (PSU) as instructed in the denial notification.
In addition to appealing an adverse action not related to eligibility, the MDCP waiver member may also request a State Fair Hearing by contacting PSU.
If an applicant, member, or legally authorized representative (LAR) wishes to request a fair hearing with the managed care organization (MCO) not related to program eligibility they may contact the MCO as instructed on the denial notification.
7310 Program Support Unit Coordination
Revision 22-3; Effective Dec. 1, 2022
When a request for a State Fair Hearing about Medically Dependent Children Program (MDCP) eligibility is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the Texas Health and Human Services Commission Appeals Division within five calendar days from the date of the request. Upon receipt of the fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary.
Form H4800 records the names, titles, addresses and phone numbers of all persons, or their designees, who should attend the hearing. For appeal issues related to service delivery, enter the names of the designated managed care organization (MCO) staff and the designated backup.
Depending on the issue being appealed, the following staff must attend:
- MCO (whenever possible, this should be the individual who completed the assessment) and Texas Medicaid & Healthcare Partnership (TMHP) (for medical necessity denials);
- MCO (for denials of individual service plans (ISPs) over the cost ceiling); and
- Medicaid for the Elderly and People with Disabilities (MEPD) (for financial denials).
The MCO must ensure that the appropriate staff members who have firsthand knowledge of the member’s appeal are able to speak and provide relevant information on the case and attend all State Fair Hearings as scheduled.
7311 Fair Hearings and Appeals Procedures
Revision 22-3; Effective Dec. 1, 2022
If a member requests a State Fair Hearing, the managed care organization (MCO) completes and submits the request via the Texas Integrated Eligibility Redesign System (TIERS) to the appropriate State Fair Hearings office, within five days of the member's request for a State Fair Hearing.
TIERS generates a hearing packet, which includes:
- Form H4803, Notice of Hearing
- Form H4800, Fair Hearing Request Summary
Managed care organizations (MCOs) receive a copy of Forms H4800 and H4803, identifying the hearings officer assigned to the appeal and the date, time, and location of the hearing.
7312 Evidence Packet
Revision 22-3; Effective Dec. 1, 2022
All related documentation necessary to support the determination on an appeal must be uploaded into the Texas Health and Human Services Commission (HHSC) State Benefits Portal and mailed to the appellant at least 10 business days before the hearing. Each entity involved in the action taken is responsible for preparing its evidence packet and uploading it to the HHSC State Benefits Portal. Within five business days of notification that the State Fair Hearing is set, the MCO will prepare an evidence packet for submission to the HHSC State Fair Hearings staff and send a copy of the packet to the member. All documentation must be neatly and logically organized, and all pages numbered.
The following are examples of documentation that may be submitted as evidence and the entity responsible for uploading that information to the HHSC State Benefits Portal:
- Managed care organization (MCO):
- MCO policy handbook, STAR Kids Handbook or STAR Kids contract and STAR Kids Managed Care Manual;
- summary of events;
- other documentation supportive of the determination, such as documentation of phone calls and visit summaries; and
- copies of the signed Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and all relevant attachments;
- Medicaid for the Elderly and People with Disabilities Centralized Representation Unit:
- documentation supportive of the financial determination, including official documentation forms and phone calls; and
- a copy of the original signed denial form;
- Texas Medicaid & Healthcare Partnership (TMHP):
- a copy of the STAR Kids Screening and Assessment Instrument (SK-SAI); and
- other documentation supporting the determination; and
- Program Support Unit: Refer to procedures outlined in the Program support Unit Operational Handbook, Section 7000, Applicant or Member Complaints and State Fair Hearings.
7320 Additional State Fair Hearing Requirements and Information
Revision 22-3; Effective Dec. 1, 2022
7321 Presentation of the Evidence Packet
Revision 22-3; Effective Dec. 1, 2022
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 managed care organization (MCO) receives a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time, and location of the hearing.
Documentation contained in the evidence packet is not considered in the hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, the agency or MCO representative must present the packet, ask that it be admitted 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 Ned Flanders. Pages 1-10 contain information relating to the completion of Form 2603, STAR Kids, Individual Service Plan (ISP) Narrative. Pages 11-15 contain policy from the STAR Kids Handbook that relates directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant on March 2, 2016."
The hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the hearings officer explains the reasons for excluding the material. Any documents admitted by the hearings officer are considered when a decision is rendered.
7322 Hearing Decision
Revision 22-3; Effective Dec. 1, 2022
After the hearing, the hearings officer sends a hearing decision to the appellant and copies to individuals listed on Form H4800, Fair Hearing Request Summary.
If the determination on appeal is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action.