7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program

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7210 Timely or Non-timely State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

Only an applicant, member, guardian or authorized representative (AR) may request a state fair hearing. The applicant, member or AR may request a state fair hearing orally or in writing.

A timely state fair hearing request for a STAR+PLUS Home and Community Based Services (HCBS) program denial is received by Program Support Unit (PSU) staff within 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for a STAR+PLUS HCBS program denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

PSU staff must create the appeal in the Texas Integrated Eligibility Redesign System (TIERS) for all state fair hearing requests that are received, except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. PSU staff must notify the Centralized Representative Unit (CRU) by creating an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits Portal if a fair hearing request is received for a MEPD or TW financial denial. PSU staff or the data entry representative (DER) must refer to Appendix XXI, Creating an Appeal in TIERS, and Appendix XXXII, Creating an Appeal Task in the HHSC Benefits Portal, when creating records.

The hearings officer will determine if there is good cause for a non-timely state fair hearing request. The applicant or member is not eligible for a state fair hearing if the hearings officer determines there is no good cause.

7211 PSU Staff Procedures for Completing Form 4800-D

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive an oral or written appeal request related to STAR+PLUS Home and Community Based Services (HCBS) program eligibility denial or termination from an:

applicant;
member; or
authorized representative (AR).

PSU staff must create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, within five days from the date a fair hearing request is received.

PSU staff must complete the following activities within three days of receipt of the state fair hearing request:

complete Form 4800-D, Fair Hearing Request Summary, ensuring all persons who should attend the state fair hearing are documented; and
email Form 4800-D to the data entry representative (DER) and DER supervisor.

The DER must enter the information on Form 4800-D in TIERS within two days.

Depending on the issue being appealed, PSU staff must enter the following staff on Form 4800-D:

For medical necessity/level of care (MN/LOC) denial by Texas Medicaid & Healthcare Partnership (TMHP):
- TMHP representative as the Agency Representative;
- TMHP 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.
For Supplemental Security Income (SSI) denial by Social Security Administration (SSA):
- PSU staff as the Agency Representative;
- PSU supervisor as the Agency Supervisor;
- no Agency Witness is entered; and
- MCO representative and MCO supervisor as the Observer
For other denial reasons (excluding MEPD or TW financial denials):
- MCO representative as the Agency Representative;
- MCO supervisor as the Agency Supervisor;
- MCO representative as the Other Participants; and
- PSU staff and PSU supervisor as the Observer.

PSU staff must contact the MCO if there is any doubt as to who should be listed on Form 4800-D.

PSU must complete the following activities when completing Form 4800-D:

answer all questions in Section 3, Appellant Details Programs;
always answer “No” to the question, “Is there a good cause for non-timely?” in Subsection D, Summary of Agency Action and Citation, since this question only applies to TW programs; and
indicate the individual service plan (ISP) begin and end dates, as applicable, in Subsection D.

PSU staff must refer to Form 4800-D instructions for more specific directions for form completion and transmittal.

PSU staff must refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

7212 DER Procedures for Entering State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

The data entry representative (DER) creates a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to document the state fair hearing request when the DER receives Form 4800-D, Fair Hearing Request Summary, from Program Support Unit (PSU) staff. The HEART case record and Community Services Interest List (CSIL) record must remain open until a state fair hearing decision is rendered.

The DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form 4800-D, following the instructions in Appendix XXI, Creating an Appeal in TIERS. The DER must use the Manage Office Resources (MOR) search function in TIERS when adding PSU staff, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP), or Texas Health and Human Services Commission (HHSC) representatives as participants. TIERS will assign an appeal identification (ID) number once the DER completes all required fields. The DER must send a copy of the TIERS generated Form H4800, Fair Hearing Request Summary, to PSU staff and upload a copy to the HEART case record.

7213 Generation of the State Fair Hearing Packet

Revision 19-13; Effective November 5, 2019

The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet, which is available to state fair hearing participants other than the applicant, member or authorized representative (AR), such as Texas Health and Human Services Commission (HHSC), the managed care organization (MCO) or Texas Medicaid & Healthcare Partnership (TMHP). A partial state fair hearing packet includes:

Form H4800, Fair Hearing Request Summary; and
Form H4803, Notice of Hearing.

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in TIERS that a state fair hearing has been scheduled. The alert in TIERS identifies the hearings officer assigned to the state fair hearing and the date and time of the state fair hearing. PSU staff use this information to monitor for the decision of the state fair hearing. PSU staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) financial denial.

Once a state fair hearing has been scheduled, TIERS generates a full state fair hearing packet, which the hearings officer sends to the applicant, member or AR. A full state fair hearing packet includes:

Form H4800;
Form H4803;
Fair Hearing Procedures (PDF); and
Form H4806, Request for Another Appointment - Request to Withdraw.

7214 State Fair Hearing Evidence Packet

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must complete the following activities on the same day PSU staff enter the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS):

prepare a state fair hearing evidence packet;
mail the state fair hearing evidence packet to the applicant, member or authorized representative (AR);
upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal following the instructions in Section 7231, Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal;
upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
document the HEART case record.

PSU staff must not enter state fair hearing requests for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) Medicaid financial denials. The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to MEPD and TW financial denials. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

PSU staff must ensure documentation on Form 4800-D, Fair Hearing Request Summary, clearly states the state fair hearing is for the STAR+PLUS Home and Community Based Services (HCBS) program.

The STAR+PLUS HCBS state fair hearing evidence packet includes:

Form 4801, State Fair Hearing Evidence Packet Cover Page;
Form H2065-D, Notification of Managed Care Services;
the appropriate handbook section, as notated on Form H2065-D;
Appendix XX, STAR+PLUS HCBS Program Eligibility TAC; and
for MN/Level of Care (MN/LOC) denials or terminations, Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment.

PSU staff must ensure all state fair hearing evidence packets are complete, organized and all pages are numbered to support the agency’s action on appeal.

Other agencies that may be involved in a state fair hearing, such as the managed care organization (MCO), Centralized Representation Unit (CRU) or Texas Medicaid & Healthcare Partnership (TMHP) will:

generate their own state fair hearing evidence packet;
upload their state fair hearing evidence packet to the HHSC Benefits Portal; and
mail their state fair hearing evidence packet to the applicant, member or AR.

The hearings officer mails Form H4803 to the applicant, member or AR when the state fair hearing is first requested. The applicant, member or AR may fax or mail evidence to the hearings officer if desired. The applicant, member or AR gets the hearings officer’s contact information from Form H4803, Notice of Fair Hearing. The hearings officer shares any evidence submitted by the applicant, member or AR with HHSC.

7215 Changes to the State Fair Hearing Request Summary

Revision 19-13; Effective November 5, 2019

After the data entry representative (DER) has added information from Form 4800-D, Fair Hearing Request Summary, in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, Program Support Unit (PSU) staff may learn of subsequent changes such as change of address. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials. When subsequent changes occur, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the DER who will check TIERS to identify if a hearings officer has been assigned to the case. The DER must ensure documentation on Form H4800-A clearly states this is a state fair hearing for the STAR+PLUS Home and Community Based Services (HCBS) program. The appeal identification (ID) number assigned by TIERS must be documented in the designated space on Form H4800-A.

If a hearings officer is assigned, the DER must upload Form H4800-A in the Texas Health and Human Services Commission (HHSC) Benefits portal as soon as possible, but no later than 10 days of becoming aware of the change.

Delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.

7220 Processing a State Fair Hearing Request

Revision 19-13; Effective November 5, 2019

7221 Type of Denials

Revision 19-13; Effective November 5, 2019

An applicant, member, guardian or authorized representative (AR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member or AR requests a state fair hearing for program denials. PSU staff notify the Centralized Representative Unit (CRU) if it is a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial using the Texas Health and Human Services Commission (HHSC) Benefits portal. PSU staff create all other state fair hearing request in TIERS. The method in which the state fair hearing is requested depends on the action being appealed. PSU staff must determine if the state fair hearing action is:

a medical necessity (MN) denial (Refer to Section 7221.1, Medical Necessity Denial by TMHP) below;
a financial denial by MEPD or TW (Refer to Section 7221.2, Financial Denial by MEPD or TW);
a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA) (Refer to Section 7221.3, SSI Denial by the SSA; or
for any other denial reasons (Refer to Section 7221.4, Other Denial Reasons).

7221.1 Medical Necessity Denial by TMHP

Revision 19-13; Effective November 5, 2019

If the action is related to a medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP), the managed care organization (MCO) and TMHP representatives are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff upload Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available), to the Texas Health and Human Services Commission (HHSC) Benefits portal to allow the TMHP representative to include Form H2065-D in TMHP’s evidence packet. PSU staff do not attend state fair hearings for MN denials.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the TMHP representative and TMHP supervisor as the Agency Representative and Agency Representative Supervisor.

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

TMHP representative as the Agency Representative;
TMHP supervisor as the Agency Representative Supervisor;
MCO representative and MCO supervisor as the Agency Witness; and
PSU staff and PSU supervisor as the Observer.

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the Observer will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an MN, on the Agency Representative field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down menu.

When Form 4800-D is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the STAR+PLUS HCBS program interest list while an MN denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the MN denial 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.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as Observer are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

7221.2 Financial Denial by MEPD or TW

Revision 19-13; Effective November 5, 2019

If the state fair hearing decision is related to a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial for a medical assistance only (MAO) applicant or member, Program Support Unit (PSU) staff must forward the request to the Centralized Representation Unit (CRU). CRU is required to attend the state fair hearing to represent STAR+PLUS Home and Community Based Services (HCBS) program financial denials.

Within one business day of receipt of the request, PSU staff must create the following:

an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits portal in the Appeals/RFR tab for the CRU relating to a financial denial for an MAO applicant or member. Refer to Appendix XXXII, Create an Appeal Task in the HHSC Benefits Portal; and
an email to CRU at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox that includes:
- a subject line that reads: STAR+PLUS HCBS Program Appeal Request – XX [applicant’s or member’s first and last name initials];
- applicant or member name;
- Medicaid identification (ID) number or Social Security number (SSN);
- Texas Integrated Eligibility Redesign System (TIERS) Case Number;
- type of service (i.e., STAR+PLUS HCBS program);
- specific information requesting the MEPD or TW financial denial case remain open during the state fair hearing, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. For example, the MEPD or TW financial denial case may need to remain open pending a state fair hearing decision regarding MN. PSU staff must notify the CRU to keep the MEPD or TW financial denial case open pending the state fair hearing decision;
- a copy of Form H2065-D, Notification of Managed Care Program Services; and
- “observer” contact information (PSU staff and PSU supervisor);
a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) documenting:
- the receipt date of the state fair hearing request; and
- notification to the CRU for completion of Form 4800-D, Fair Hearing Request Summary, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

Once the CRU receives a state fair hearing request, the CRU sends an email reply to PSU staff and the PSU supervisor listed as "observers" within five days notifying of the completion of Form 4800-D and the appeal identification number (ID). Once PSU staff receive the notification, PSU staff upload the notification in HEART, following the instructions in Appendix XXXIII, and monitor the appeal until the state fair hearing decision is rendered.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS program interest list while an MEPD or TW financial denial are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the MEPD or TW financial denial 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.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as "observer" are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must prepare the evidence packet and attend the for Supplemental Security Income (SSI) denials by the Social Security Administration (SSA). Refer to Section 7230, State Fair Hearing Actions, for PSU staff responsibilities for preparing the state fair hearing evidence packet.

The following are examples of documentation that PSU staff must submit as evidence and are responsible for uploading in the Texas Health and Human Services (HHSC) Benefits Portal:

Form H4803, Notice of Hearing, as a cover sheet;
copy of the citation, Title 1 Texas Administrative Code (TAC) Section 353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
Section 6200.4, Financial Eligibility; and
Form H2065-D, Notification of Managed Care Program Services.

Refer to Appendix XXI, Creating an Appeal in TIERS, for more information on PSU staff completion of Form H4800, Fair Hearing Request Summary.

Continuation of STAR+PLUS HCBS program benefits during a state fair hearing does not apply to SSI denials. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for more information. PSU staff must not return an applicant or member to the STAR+PLUS HCBS program interest list while an SSI denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the hearings officer renders a decision on the SSI denial. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the hearings officer sustains the denial.

The PSU staff and PSU supervisor entered as “Agency Representative” and “Agency Representative Supervisor” receive an alert in TIERS when the hearings officer renders a state fair hearing decision.

Refer to Section 7400, State Fair Hearing Decision Actions, for more information about notification requirements for required actions following a state fair hearing decision.

7221.4 Other Denial Reasons

Revision 19-13; Effective November 5, 2019

Other denial reasons include, but are not limited to:

unable to locate the applicant or member;
unable to obtain physician signature; or
cost of the individual service plan (ISP) exceeds the maximum amount allowed.

If the action is related to other denial reasons, the managed care organization (MCO) staff are required to prepare the evidence packet and attend the state fair hearing. PSU staff do not attend state fair hearings related to other denial reasons.

Program Support Unit (PSU) staff complete Form 4800-D, Fair Hearing Request Summary, entering the MCO staff as the Agency Representative and Agency Representative Supervisor.

MCO staff as the Agency Representative;
MCO supervisor as the Agency Representative Supervisor;
MCO staff as the Agency Witness; and
PSU staff and PSU supervisor as the Observer.

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to other denial reasons, on the Agency Representative field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?." PSU staff will be required to select "No" in the drop-down menu.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS program interest list while other denial reasons are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the other denial reason 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.

When a state fair hearing decision is rendered by the hearings officer, the PSU staff and PSU supervisor entered as "observer” are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

7222 Continuation or Termination of Services

Revision 19-13; Effective November 5, 2019

7222.1 Continuation of STAR+PLUS HCBS Program During a State Fair Hearing

Revision 22-1; Effective January 31, 2022

Continuation of STAR+PLUS Home and Community Based Services (HCBS) program benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials. For all other denials, the STAR+PLUS HCBS program must continue until the hearings officer issues a decision if the member or authorized representative (AR) files a state fair hearing requesting continued benefits:

within the adverse action notification period of the STAR+PLUS HCBS program termination; or
by the effective date of the action pending the state fair hearing.

The deadline is whichever date is later.

Program Support Unit (PSU) staff must notify the following parties within three business days if the member requests a state fair hearing within the adverse action notification period or by the effective date of the action:

the managed care organization (MCO) by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, notifying the MCO to continue providing services until the hearings officer renders a decision. PSU staff must also upload a copy of Form H2067-MC in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
the Centralized Representation Unit (CRU) by email at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox, including:
- a subject line that reads: STAR+PLUS HCBS Request for Continued Benefits – XXX.XXX [first three letters of the applicant’s or member’s first and last name] #### [last four digits of the case number];
- applicant or member name;
- Medicaid identification (ID) number;
- HHSC Benefits Portal Appeal ID number, if available;
- Texas Integrated Eligibility Redesign System (TIERS) Case Number;
- type of service (i.e., STAR+PLUS HCBS program);
- reason for termination (e.g., medical necessity denial);
- specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial case remain open during the state fair hearing. For example, the MEPD or TW financial denial case may need to remain open pending a state fair hearing decision regarding MN;
- a copy of Form H2067-MC, Managed Care Programs Communication, from the managed care organization (MCO) indicating the member requested continued benefits, if applicable;
- a copy of Form H2065-D, Notification of Managed Care Program Services; and
- the witnesses’ contact information, such as the MCO representative and the designated MCO back-up.

PSU staff must extend the current individual service plan (ISP) for four months or until the state fair hearing decision is rendered if the hearings officer's decision will not be made until after the ISP expiration date. PSU staff must not extend the medical necessity and level of care (MN/LOC) records in the Service Authorization System Online (SASO). PSU staff must not mail Form H2065-D to the member or authorized representative (AR) notifying of continued eligibility until the hearings officer renders a state fair hearing decision.

Example: The member’s four-month period would end on the last day of April if the ISP expiration date is December 1 and the state fair hearing decision date is December 15.

HHSC continues or reinstates services pending the state fair hearing decision if the state fair hearing is initially dismissed and then subsequently reopened, and the member or AR requests continued services. The hearings officer, in effect, voids the prior state fair hearing decision if the hearings officer sets a date for a new state fair hearing. The member must continue to receive services until the hearings officer renders a new state fair hearing decision.

7222.2 Discontinuation of STAR+PLUS HCBS Program Due to Member Not Requesting a State Fair Hearing

Revision 23-2; Effective May 15, 2023

A member’s STAR+PLUS Home and Community Based Services (HCBS) program services must continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services. The program denial date is the last day of the month of the current individual service plan (ISP) or the last day of the month in which the adverse action notification period ends, whichever is later. Refer to Section 6200, Adverse Action Notification Period, for additional information.

A member who does not request a state fair hearing with continued benefits before the effective date of the denial will not receive continued STAR+PLUS HCBS program services during the state fair hearing.

SSI members will remain enrolled in STAR+PLUS after STAR+PLUS HCBS termination. SSI members remain eligible for Medicaid state plan services, which include acute care and long-term services and supports (LTSS), such as Community First Choice (CFC), Day Activity and Health Services (DAHS), Emergency Response Services (ERS) and Personal Assistance Services (PAS).

7230 State Fair Hearing Actions

Revision 19-13; Effective November 5, 2019

7231 Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal

Revision 19-13; Effective November 5, 2019

The data entry representative (DER) must upload all evidence packets and all supporting documentation for Supplemental Security Income (SSI) denials and medical necessity (MN) denials in the Texas Health and Human Services Commission (HHSC) Benefits portal using the process described below. Refer to Section 7213, Generation of the State Fair Hearing Packet, for examples of documentation that must be submitted as evidence.

At least 12 business days prior to the state fair hearing date, the DER must:

upload the supporting documentation in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
email the supporting documentation to Program Support Unit (PSU) staff and the PSU supervisor.

Within two business days after receipt of the evidence packet in the HHSC Benefits portal, the DER must:

select the Appeals/RFR tab and ensure the appeal has been entered;
select Hearing Evidence Packets Upload and enter the appeal identification (ID) number;
select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
select Validate;
check the details to ensure the right person has been selected;
browse for the document (e.g., Form H2065-D, Notification of Managed Care Program Services); and
select Upload.

If an error is made on the Agency Representative screen when creating an appeal in the Texas Integrated Eligibility Redesign System (TIERS), the person who created the appeal can correct the error in Maintain Appeals. If an error is made on any other screen when creating an appeal in TIERS, Form H4800-A, Fair Hearing Request Summary (Addendum), must be completed and uploaded in the HHSC Benefits portal. The Agency Action Date cannot be changed.

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 22-1; Effective January 31, 2022

The hearings officer will not consider documentation in the evidence packet in the state fair hearing decision unless the packet is offered and admitted into evidence. The “Agency Representative” listed on Form H4800, Fair Hearing Request Summary, must present the packet, ask that the documents be admitted as evidence, and summarize what the packet contains. Program Support Unit (PSU) staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) denial. Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration, for PSU staff state fair hearing responsibilities. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case.

MCO Example: "I want to offer the following packet as evidence in the state fair hearing filed on behalf of Ned Flanders.

Pages 1-10 contain information relating to the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide.
Pages 11-15 contain policy from the STAR+PLUS Handbook (SPH) that relates directly to the issue in question.
Pages 16-20 contain documents signed by the applicant, member or authorized representative (AR) related to individual rights.
Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or authorized representative (AR) on March 2."

PSU Example: "I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
Page 2 contains a copy of the Title 1 Texas Administrative Code (TAC) §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program, that states the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR+PLUS HCBS program services to eligible applicants or members.
Page 3 contains a copy of the SPOPH Section 6200.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR+PLUS HCBS program services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) requirements.
Page 4 contains Form H2065-D, which was mailed to the applicant, member or AR on March 2nd."

The hearings officer then asks for objections and admits the documents into evidence. The hearings officer explains the reasons for excluding the material if the hearings officer is not able to admit any documents. The hearings officer considers any documents admitted when rendering a decision.

7233 State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or authorized representative (AR) and copies all individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff and the PSU supervisor. If the decision is sustained, PSU staff take the appropriate action.

If the state fair hearing decision is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The hearings officer renders a decision and sends the written decision to the applicant, member or AR and copies all the individuals listed on Form H4800, which includes the PSU staff and PSU supervisor. PSU staff actions required by the hearings officer must be reported back in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation screen, within the 10-day time frame designated by the hearings officer.

If the applicant, member or AR requested continued services during the state fair hearing period, PSU staff follow procedures, as described in Section 7400, State Fair Hearing Decision Actions.