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Revision 22-3; Effective Dec. 1, 2022
7610 Sustained State Fair Hearing Decisions
Revision 22-3; Effective Dec. 1, 2022
When the hearings officer’s decision sustains the denial of Medically Dependent Children Program (MDCP) waiver services, the written decision is mailed to the applicant, member, or their legally authorized representative (LAR). Copies are sent to all witnesses listed on Form H4800, Fair Hearing Request Summary.
7611 Sustained Decisions – Termination Effective Dates
Revision 22-4; Effective Dec. 1, 2022
When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the State Fair Hearing decision is known, the Medically Dependent Children Program (MDCP) waiver termination effective date varies depending on the following circumstances.
- In cases where the hearings officer's decision is 30 calendar days or more before the end of the individual service plan (ISP) in effect when the State Fair Hearing was filed, MDCP waiver termination is effective at the end of the ISP in effect at the time the State Fair Hearing was filed. See Example 1.
- When the hearings officer's decision date is less than 30 calendar 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 calendar days from the hearings officer's decision date (the date the order is signed). See Example 2.
- 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 appeal decision was made, the termination effective date is the end of the month that is 30 calendar days from the hearings officer's decision date. See Example 3.
- If the hearings officer assigns a specific medical necessity (MN) 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 the hearings officer identified as the expiration month. See Example 4.
- When the hearings officer assigns a specific MN 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. See Example 5.
- If the hearings officer assigns a specific MN expiration date that is before the end of the MN in effect when the State Fair Hearing was filed, the termination effective date is the end of the month of the original MN expiration date. See Example 6.
Examples
| Example | Conditions | Original MN/ISP Expiration Date | New Expiration Date | Hearings Officer Decision Date | Final MN/ISP Expiration Date |
|---|---|---|---|---|---|
| 1 | Hearings officer decision is more than 30 days from the original expiration date. | 1/31/22 | 5/31/22 | 11/2/21 | 1/31/22 |
| 2 | Hearings officer decision is less than 30 days from the original expiration date. | 1/31/22 | 5/31/22 | 1/15/22 | 2/28/22 |
| 3 | Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. | 1/31/22 | 5/31/22 | 2/15/22 | 3/31/22 |
| 4 | Hearings officer decision assigns a specific expiration date. | 1/31/22 | 5/31/22 | Hearings officer decision was for MN to expire on 2/15/16. | 2/29/22 |
| 5 | Hearings officer decision assigns a specific expiration date that occurs in the future. | 1/31/22 | 5/31/22 | Hearings officer decision was for MN to expire on 2/29/16. | 2/29/22 |
| 6 | Hearings officer decision assigns a specific expiration date that occurred in the past. | 1/31/22 | 5/31/22 | Hearings officer decision was for MN to expire on 12/31/21. | 1/31/22 |
7612 Reversed Appeal Decisions
Revision 23-4; Effective Dec. 1, 2023
Within two business days from the hearings officer’s decision to reverse an applicant’s or member’s Medically Dependent Children Program (MDCP) denial of the program, Program Support Unit (PSU) staff will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral:
- Notifying the managed care organization (MCO) of the hearings officer’s decision to reverse the denial of MDCP;
- Advising the MCO that MDCP services are to continue as directed in the hearings officer’s decision; and
- Requesting the MCO to submit the STAR Kids individual service plan (SK-ISP).
Within two business days from the receipt of Form H2067-MC from PSU staff, the MCO will provide PSU staff with the SK-ISP by uploading to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).
7613 Reversed Decisions – Effective Dates
Revision 22-3 Effective Dec. 1, 2022
When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) waiver eligibility, the MDCP waiver effective date for:
- members - reassessment is one day after the end of the individual service plan in effect when the state fair hearing was filed; and
- applicants - MDCP waiver denied at initial application is the first of the month following the hearings officer's decision.
When a fair hearing decision reverses a Program Support Unit (PSU) action but PSU staff cannot implement the fair hearing decision within the required time frame, PSU staff must complete the Implementation Delays screen in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation.
7620 New Assessment Required by Fair Hearing Decision
Revision 22-3; Effective Dec. 1, 2022
If the hearings officer’s final decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI), the hearing is closed as a result of this ruling. Program Support Unit (PSU) staff must notify the member 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 member may appeal the results of the new assessment. If the member chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, of Form H4800, Fair Hearing Request Summary, that the new assessment was ordered from a previous fair hearing decision.
If the member requests a State Fair Hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second fair hearing decision is implemented. For example, a Medically Dependent Children Program (MDCP) waiver member is denied MN at an annual reassessment and requests a fair hearing and services are continued. The MCO would continue services at the level the member was receiving before the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member informing him or her of the MN denial. The member then requests another fair hearing and services are continued pending the second fair hearing decision. The MCO continues services at the same level services were continued before the first fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member requests a fair hearing due to the lower RUG level, the MCO continues services at the same level services were continued before the first fair hearing.
7630 Request to Withdraw a State Fair Hearing
Revision 22-3; Effective Dec. 1, 2022
An appellant or appellant representative must request to withdraw a State Fair Hearing by sending a notice to the hearings office. The appellant or appellant representative may request withdraw of the State Fair Hearing orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing.
If the individual requesting to withdraw contacts Program Support Unit (PSU) staff, PSU staff must advise them the request to withdraw the State Fair Hearing must be provided directly to the hearings office. If PSU staff receive a written request to withdraw, PSU staff must forward this written request to the hearings office. All requests to withdraw the hearing must originate from the applicant, member or LAR, and must be made to the hearings office.
If the request to withdraw a State Fair Hearing is within five business days of the fair hearing date, the hearings officer will notify PSU by phone or email and open the conference line to inform participants of the cancellation. If the request to withdraw a State Fair Hearing is more than five business days before the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written notice to participants informing them of the fair hearing cancellation.