7500, State Fair Hearing Decision Actions

7510 Sustained State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A sustained fair hearing decision occurs when the hearings officer renders a decision to uphold the Medically Dependent Children Program (MDCP) denial or termination. For example, if an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal (request for the state fair hearing), sustaining the action on appeal. 

7510.1 Sustained State Fair Hearing Decision for Applicants

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain an applicant’s denial:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision sustained the action on appeal;
• close the Community Services Interest List (CSIL) record if the record is open;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, legally authorized representative (LAR) or medical consenter of the sustained termination. 

7510.2 Sustained State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued Medically Dependent Children Program (MDCP) benefits:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
  • hearing decision sustained the action on appeal; and
  • MCO must deliver services through the MDCP termination effective date;
• terminate the STAR Kids individual service plan (SK-ISP) and the Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7511, Sustained Decision – Termination Date;
• close the Community Services Interest List (CSIL) record if the record is open;
• for medical assistance only (MAO) members, email the Centralized Representation Unit (CRU) Unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
  • an email subject line that reads: “Sustained Benefits for MDCP – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”;
  • the member's name;
  • Medicaid identification (ID) number;
  • the type of request (i.e., notification of sustained MDCP benefits); 
  • the type of service (i.e., MDCP);
  • HHSC Benefits Portal appeal ID number;  
    the Texas Integrated Eligibility Redesign System (TIERS) case number;
  • MDCP termination effective date; and
  • the state fair hearing decision.
    • Note: CRU staff will terminate Medicaid eligibility for MAO members.
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member, legally authorized representative (LAR) or medical consenter of the sustained termination.

7510.3 Sustained State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision sustained the action on appeal;
• close the Community Services Interest List (CSIL) record if the record is open;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member, legally authorized representative (LAR) or medical consenter of the sustained termination. 

7511 Sustained Decision – Termination Effective Date

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must adjust the member’s STAR Kids individual service plan (SK-ISP) end date and terminate the SK-ISP per the fair hearings officer’s sustained decision when the member received:

• continued Medically Dependent Children Program (MDCP) benefits during the fair hearing; and
• a sustained fair hearing outcome.

The final termination effective date varies depending on the following: 

• hearings officer’s decision date;
• original SK-ISP date; and
• SK-ISP expiration date as a result of the member receiving continued MDCP benefits during the fair hearing.

See below table for further clarification of each scenario.

Scenario 1: PSU staff must adjust the extended SK-ISP end date back to the historical SK-ISP end date if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision is 30 days or more before the end of the historical SK-ISP end date. 

Scenario 2: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date (the date the order is signed) if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision date is 30 days or less before the end of the historical SK-ISP end date.

Scenario 3: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision date is: 
  • after the end of the SK-ISP in effect when the member filed the state fair hearing; and
    • before the end of the extended SK-ISP date.

7520 Reversed State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A reversed fair hearing decision occurs when the hearings officer determines the Texas Health and Human Services Commission (HHSC) action was not appropriate per policy and law. HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) benefits when the hearings officer issues a reversed fair hearing decision.

7520.1 Reversed State Fair Hearing Decision for Applicants 

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse an applicant’s denial: 

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision reversed the action on appeal;
• reactivate the STAR Kids individual service plan (SK-ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and the Enrollment Form;
• edit the SK-ISP and Enrollment Form dates in the TMHP LTCOP using the effective dates noted in Section 7521,  Reversed Decision – Effective Date; 
• close the Community Services Interest List (CSIL) record if the record is open; and
• follow current policy noted in the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) Section 2000, Medically Dependent Children Program Intake and Initial Application,  for approving Medically Dependent Children Program (MDCP) applicants.

7520.2 Reversed State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who received continued Medically Dependent

Children Program (MDCP) benefits: 

• upload Form H2067-MC, Managed Care Programs Communication , to TxMedCentral notifying the managed care organization (MCO) that the:
  • hearing decision reversed the action on appeal;
  • MDCP benefits must continue as directed in the hearings officer’s decision; and
  • MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• edit the original SK-ISP end date in the TMHP LTCOP to match the historical SK-ISP end date, if applicable;
• update the MDCP Enrollment Form in the TMHP LTCOP, if applicable;
• pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of new SK-ISP in the TMHP LTCOP;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

• edit the new SK-ISP effective date in the TMHP LTCOP using the effective date noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed; 
• close the Community Services Interest List (CSIL) record if the record is open;
• generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
• upload all applicable documents to HEART case record; and
• document and close the HEART case record.

7520.3 Reversed State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits: 

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
• hearing decision reversed the action on appeal;
• MDCP benefits must be reinstated as directed in the hearings officer’s decision; and
• MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• edit the original SK-ISP and Enrollment Form end date in the TMHP LTCOP to match the historical SK-ISP and Enrollment Form end date, if applicable;
• pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of the new SK-ISP in the TMHP LTCOP;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

• edit the new SK-ISP and Enrollment Form effective date in the TMHP LTCOP using the effective dates noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed;
• close the Community Services Interest List (CSIL) record if the record is open;
•  generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
• for medical assistance only (MAO) members, email the Enrollment Resolution Services (ERS) Unit staff. The email to the ERS Unit must include the following information:
  • a subject line that reads: “Hearings Officer Decision – STAR Kids MDCP – Reversed Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”; 
  • the member's name;
  • Medicaid identification (ID) number;
  • Health and Human Services Commission (HHSC) Benefits Portal appeal ID number;
  • the Texas Integrated Eligibility Redesign System (TIERS) case number;
  • SK-ISP receipt date;
  • SK-ISP begin date;
  • SK-ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • the state fair hearing decision; and
  • Form H2065-D; 
• for MAO members, email the Centralized Representation Unit (CRU) staff at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
  • a subject line that reads: “Reinstatement of Benefits for MDCP – Appeal ID ####### for XX [first letter of the member's first and last name]”;
  • the member's name;
  • Medicaid ID number;
  • the type of request (i.e., reinstate Medicaid eligibility); 
  • the type of service (i.e., MDCP);
  • HHSC Benefits Portal appeal ID number;
  • the TIERS number;
  • TIERS Medicaid eligibility effective date;
  • the state fair hearing decision; and
  • Form H1746-A, MEPD Referral Cover Sheet; 
• upload all applicable documents to HEART case record; and
• document and close the HEART case record.

7521 Reversed Decision – Effective Date

Revision 23-4; Effective Aug. 21, 2023

The effective begin date for the STAR Kids individual service plan (SK-ISP) for a reversed fair hearing decision depends on if the appellant is an applicant, member with continued Medically Dependent Children Program (MDCP) benefits or member without MDCP continued benefits.

The SK-ISP begin date for an applicant is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer.

The SK-ISP begin date for a member who received continued MDCP benefits is the first day of the month following the end of the SK-ISP in effect when the state fair hearing was filed.

The SK-ISP begin date for a member who did not receive continued MDCP benefits is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer. 

Program Support Unit (PSU) staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with the Central Representation Unit (CRU). 
 

7522 New Assessment Required by State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018

If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed as a result of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) 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 applicant, member or LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must indicate in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800, Fair Hearing Request Summary, and also during the state fair hearing that the new assessment was ordered from a previous state fair hearing decision.

If the member or LAR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a Medically Dependent Children Program (MDCP) member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving prior to 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 or LAR informing him or her of the MN denial. The member or LAR then request another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided prior to the first state fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member or LAR requests a state fair hearing due to the lower RUG level, the MCO continues services at the same level services were provided prior to the first state fair hearing. 

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018

An applicant, member or legally authorized representative (LAR) may withdraw the state fair hearing request orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing. If the applicant, member or LAR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or LAR to contact the hearings officer of the withdrawal by calling the hearings officer’s telephone number listed on Form H4803. If the applicant, member or LAR send a written request to withdraw to PSU staff, PSU staff must forward the written request to the hearings officer listed on Form H4803.

A state fair hearing will not be dismissed based on a PSU staff decision to change the adverse action. All requests to withdraw the state fair hearing must originate from the applicant, member or LAR and must be made to the hearings officer.

If the applicant, member or LAR request to withdraw the state fair hearing more than five business days prior to the state fair hearing date, the hearings officer will process the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written decision to participants informing them of the state fair hearing cancellation.

If the applicant, member or LAR request to withdraw the state fair hearing within five business days of the state fair hearing date, the hearings officer will notify PSU staff by telephone or email and open the conference line to inform participants of the cancellation.