5400, Fair Hearings for Medically Fragile or GR

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must enter an appeal in Texas Integrated Eligibility Redesign System (TIERS) if a fair hearing request is received from the applicant, member, or authorized representative (AR) for an individual service plan (ISP) that exceeds the cost limit.

PSU staff must use the issue code 88-ISP Over the Cost Cap (Medically Fragile) when the data entry representative (DER) is completing Form 4800-D, Fair Hearing Request Summary, or when PSU staff are creating an appeal in TIERS.

PSU staff must enter the following information in TIERS when a fair hearing request for a Medically Fragile group case is received:

  • Office of Medical Director (OMD) staff as the Agency Representative;
  • OMD Unit staff supervisor as the Agency Supervisor;
  • Managed care organization (MCO) representative and MCO supervisor as the Agency Witness; and
  • PSU staff and PSU supervisor as the Observer.
  • MCO representative as the Agency Representative;
  • MCO supervisor as the Agency Supervisor;
  • no Agency Witness is entered; and
  • PSU staff and PSU supervisor as the Observer.

PSU staff must enter the following information in TIERS when any other fair hearing request is received for an ISP more than the cost limit, including cases reviewed for the general revenue (GR) funds process:

  • MCO representative as the Agency Representative;
  • MCO supervisor as the Agency Supervisor;
  • no Agency Witness is entered; and
  • PSU staff and PSU supervisor as the Observer. 

PSU staff must not put an applicant or member name back on the STAR+PLUS Home and Community Based Services (HCBS) program interest list while a denial related to an ISP exceeding the cost limit for the Medically Fragile group or GR funds process is in the state fair hearing process.

PSU staff must take appropriate action to certify or deny the case once the state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.