4500, Hearing Decision Actions

Revision 14-1; Effective March 3, 2014

4510 Sustained Appeal Decisions

Revision 14-1; Effective March 3, 2014

When the hearings officer’s decision sustains the denial of HCBS STAR+PLUS Waiver (SPW) services, Program Support Unit (PSU) staff must:

• notify the member via telephone or letter (if the individual does not have a telephone) of the hearings officer's decision and the termination effective date;
• notify the managed care organization via Form H2067-MC, Managed Care Programs Communication, to deliver services through the SPW termination effective date if services were continued during the appeal process;
• terminate SPW (service group 19) services in the Service Authorization System effective the SPW termination effective date (see Section 4511 below);
• notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist of the hearings officer's decision and the termination effective date for non-Supplemental Security Income (SSI) recipients. MEPD terminates Medicaid eligibility for non-SSI recipients; and
• notify Managed Care Operations of the hearings officer's decision and the termination effective date for non-SSI recipients. Managed Care Operations disenrolls non-SSI recipients from STAR+PLUS.

PSU must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the member of the sustained denial.

4511 Sustained Decisions – Termination Effective Dates

Revision 12-3; Effective October 1, 2012

When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the appeal decision is known, the HCBS STAR+PLUS Waiver (SPW) termination effective date will vary depending on the circumstances:

• In cases where the hearings officer's decision is 30 calendar days or more prior to the end of the individual service plan (ISP) in effect when the appeal was filed, SPW termination is effective at the end of the ISP in effect at the time the appeal 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 appeal 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 as recorded on Page 1 of Form H4807, Action Taken on Hearing Decision). See Example 2.
• When the hearings officer's decision date is after the end of the ISP in effect when the appeal 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 (as recorded on Page 1 of Form H4807). See Example 3.
• If the hearings officer assigns a specific medical necessity (MN)/ISP expiration date not equal to the last day of the month but after the end of the ISP in effect when the appeal 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/ISP 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 appeal was filed, the termination effective date is the end of that ISP period. See Example 5.
• If the hearings officer assigns a specific MN/ISP expiration date that is before the end of the MN/ISP in effect when the appeal was filed, the termination effective date is the end of the month of the original MN/ISP expiration date. See Example 6.

Examples

4520 Reversed Appeal Decisions

Revision 14-1; Effective March 3, 2014

When the hearings officer’s decision reverses the denial of an HCBS STAR+PLUS Waiver (SPW) applicant or member, Program Support Unit staff must:

• notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, that SPW services are to continue as directed in the decision and to request Form H1700-1, Individual Service Plan — SPW (Pg. 1);
• send Form H2065-D, Notification of Managed Care Program Services, within two business days to the:
  • SPW member who was terminated at reassessment to notify him the denial decision was reversed and he is eligible for SPW services for the new individual service plan (ISP) year;
  • SPW applicant who was denied at application to notify him of eligibility for SPW services;
  • MCO regarding applicants and the SPW effective date; and
  • Managed Care Operations staff regarding applicants and the SPW effective date and enrollment date;
• ensure the ISP is registered or updated in the Service Authorization System with the correct effective dates; and
• notify Medicaid for the Elderly and People with Disabilities, as appropriate, to continue Medicaid eligibility.

4521 Reversed Decisions – Effective Dates

Revision 19-3; Effective December 2, 2019

When the hearings officer’s decision reverses the denial of HCBS STAR+PLUS Waiver (SPW) eligibility, the SPW effective date for:

• reassessment is one day after the end of the individual service plan in effect when the appeal was filed; and
• SPW denied at application is the first of the month following the hearings officer's decision recorded on Form H4807, Action Taken on Hearing 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 Section C, Implementation Delays, on Form 4807-D, Action Taken on Hearing Decision. Form 4807-D must be submitted within the required time frame.

4522 New Assessment Required by Fair Hearing Decision

Revision 19-3; Effective December 2, 2019

If the hearings officer’s final decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Medical Necessity and Level of Care (MN/LOC) Assessment, 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. 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 4800-D, Fair Hearing Request Summary, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision.

If the member requests an appeal 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 STAR+PLUS Waiver (SPW) member is denied medical necessity (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 prior to the MN denial. The hearings officer then orders a new MN/LOC Assessment which results in another MN denial. PSU staff send a notice to the member informing him of the MN denial. The member then requests another fair hearing and services are continued pending the second fair hearing decision. The MCO would continue services at the same level services were continued prior to 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 would continue services at the same level services were continued prior to the first fair hearing.

4523 Request to Withdraw an Appeal

Revision 14-1; Effective March 3, 2014

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. Program Support Unit (PSU) 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 PSU staff regarding the withdrawal, PSU 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 PSU staff, PSU staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on a PSU 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 PSU 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 and a written notice will be sent to participants informing them of the fair hearing cancellation.