7400, State Fair Hearing Decision Actions

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

State fair hearing decision terminology used by the hearings officer is defined below:

• Sustained – This decision type is used when the hearings officer determines HHSC’s action was appropriate per policy and law. 
• Sustained with Instructions – This decision type is used when the hearings officer determines HHSC’s action was appropriate per policy and law, however new information has been provided and more action is required.
• Reversed – This decision type is used when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate services.

7410 Sustained State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

When a hearings officer renders a sustained decision, the denial is upheld. 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), essentially sustaining the action on appeal.

When the hearings officer’s decision sustains the denial of the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must:

• notify the managed care organization (MCO) by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, to deliver services through the STAR+PLUS HCBS program termination effective date, if services were continued during the state fair hearing process;
• terminate STAR+PLUS HCBS program (service group (SG) 19) services by end-dating the individual service plan (ISP) in the Service Authorization System Online (SASO) effective the STAR+PLUS HCBS program termination effective date (Refer to Section 7411, Sustained Decision - Termination Effective Date);
• email Form H1746-A, MEPD Referral Cover Sheet, to the Centralized Representation Unit (CRU) at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox of the hearings officer's decision and the termination effective date for medical assistance only (MAO) members. The CRU will terminate Medicaid eligibility for MAO members; and
• send an email to the Enrollment Resolution Services (ERS) Unit mailbox as notification of the hearings officer's decision and the termination effective date for MAO members. ERS Unit will disenroll MAO members from the STAR+PLUS HCBS program. The email to the ERS Unit mailbox must include:
  • a subject line that reads: Hearings Officer Decision - STAR+PLUS HCBS Program Sustained Appeal – XX [applicant’s or member’s first and last name initials];
  • applicant or member name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • HHSC Benefits portal Appeal ID number;
  • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
  • type of service (i.e., STAR+PLUS HCBS program);
  • termination effective date (if applicable);
  • a copy of Form H1746-A;
  • a copy of Form H2067-MC;
  • a copy of the state fair hearing decision; and
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions, including:
  • a copy of the state fair hearing decision;
  • Form H1746-A;
  • Form H1746-A fax confirmation page;
  • Form H2067-MC;
  • a screenshot of Form H2067-MC uploaded to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV;
  • emails sent to, and received from, the ERS Unit;
  • a screenshot of the TMHP LTCOP banner;
  • a screenshot of the TMHP LTCOP history; and
  • a screenshot of the HHSC Benefits portal.

PSU staff must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, member or authorized representative (AR) of the sustained denial. 

7411 Sustained Decision – Termination Effective Date

Revision 19-13; Effective November 5, 2019

When the STAR+PLUS Home and Community Based Services (HCBS) program is terminated at reassessment because the member does not meet eligibility criteria and services are continued until the state fair hearing decision is known, the termination effective date will vary depending on the following circumstances:

• In cases where the hearings officer's decision is 30 days or more prior to the end of the individual service plan (ISP) in effect when the state fair hearing was filed, STAR+PLUS HCBS program termination is effective at the end of the ISP in effect at the time the state fair hearing was filed. Refer to Example 1 below.
• When the hearings officer’s decision date is less than 30 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 days from the hearings officer's decision date (the date the order is signed). Refer to Example 2 below.
• 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 state fair hearing decision was made, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date. Refer to Example 3 below.
• If the hearings officer assigns a specific medical necessity (MN) or ISP 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 that the hearings officer identified as the expiration month. Refer to Example 4 below.
• When the hearings officer assigns a specific MN or 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 state fair hearing was filed, the termination effective date is the end of that ISP period. Refer to Example 5 below.
• If the hearings officer assigns a specific MN or ISP expiration date that is before the end of the MN or ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month of the original MN or ISP expiration date. Refer to Example 6 below.

Examples

7420 Reversed State Fair Hearing Decision

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the hearings officer’s decision to reverse the denial or termination of STAR+PLUS Home and Community Based Services (HCBS) program within two business days by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. PSU staff must notate the following on Form H2067-MC:

• STAR+PLUS HCBS program services are to continue as directed in the hearings officer’s decision, as applicable; and
• the MCO must upload a new ISP to TxMedCentral or to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), as applicable.

PSU staff must complete the following activities for applicants within two business days of receipt of the ISP:

• manually generate Form H2065-D, Notification of Managed Care Program Services;
  • for all applicants, the ISP begin date will be the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
• mail Form H2065-D to the applicant;
• upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV;
• ensure the ISP is updated in the Service Authorization System Online (SASO) with the correct effective dates by following the instructions in Section 9000, Service Authorization System Online Help File;
• for medical assistance only (MAO) applicants, notify Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
  • a subject line that reads: Reversed Hearing Decision – STAR+PLUS HCBS Appeal for XX [first letter of the applicant’s first and last name]. For example, the email subject line for a STAR+PLUS HCBS program termination reversal for Ann Smith would be “Reversed Hearing Decision – STAR+PLUS HCBS Appeal for AS”;
  • the applicant’s name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • Health and Human Services Commission (HHSC) Benefits portal Appeal ID number;
  • Texas Integrated Eligibility Redesign System (TIERS) case number;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • Form H2065-D; and
  • the state fair hearing decision;
• for MAO applicants, notify Centralized Representation Unit (CRU) staff by email at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to CRU staff must include:
  • o    a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the applicant’s first and last name];
  • o    the applicant’s name;
  • o    Medicaid ID number or SSN;
  • o    type of request (i.e., continue or reinstate Medicaid eligibility); 
  • o    type of service (i.e., STAR+PLUS HCBS program);
  • o    HHSC Benefits portal Appeal ID number;
  • o    TIERS case number;
  • o    TIERS Medicaid eligibility effective date;
  • o    Form H1746-A , MEPD Referral Cover Sheet; 
  • o    Form H2065-D; and
  • o    the state fair hearing decision;
• upload all applicable documents to the 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 and close the HEART case record.

PSU staff must complete the following activities for members within two business days of receipt of the ISP:

• electronically generate Form H2065-D in the TMHP LTCOP;
  • for a member who did not receive continued benefits, the ISP begin date will be the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
  • for a member who did receive continued benefits, the ISP begin date will be the first day of the month following the termination date;
• mail Form H2065-D to the member;
• ensure the ISP is updated in SASO with the correct effective dates by following the instructions in Section 9000; 
• for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
  • a subject line that reads: Reversed Program Hearing Decision - STAR+PLUS HCBS Program - Appeal – XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • Form H2065-D; and
  • the state fair hearing decision;
• for MAO members, notify CRU staff by email at the HHSC AES Fair Hearings mailbox. The email to CRU staff must include:
  • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request (i.e., continue or reinstate Medicaid eligibility); 
  • type of service (i.e., STAR+PLUS HCBS program);
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • TIERS Medicaid eligibility effective date;
  • Form H1746-A; 
  • Form H2065-D; and
  • the state fair hearing decision;  
• upload all applicable documents to the HEART case record following the instructions in Appendix XXXIII; and
• document and close the HEART case record.

7421 Reversed Decision – Effective Date

Revision 19-13; Effective November 5, 2019

When the hearings officer’s decision reverses the denial of STAR+PLUS Home and Community Based Services (HCBS) program eligibility, the effective date Program Support Unit (PSU) staff enter on Form H2065-D, Notification of Managed Care Program Services is:

• for applicants, the first of the month following the hearings officer’s decision; or
• for members at reassessment, one day after the end of the individual service plan (ISP) in effect when the state fair hearing was filed.

When a state fair hearing decision reverses a Program Support Unit (PSU) program denial but PSU staff cannot implement the state fair hearing decision within the required time frame, PSU staff must complete Section B of Form H4807, Action Taken on Hearing Decision. PSU staff must attach and send Form H4807 by email to the data entry representative (DER). Information on Form H4807 must be entered by the DER on the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Refer to Section 7233, State Fair Hearing Decision, and Section 7310, Action Taken on the State Fair Hearing Decision, for the required time frames.

PSU staff may need to coordinate effective dates of reinstatement with the Centralized Representative Unit (CRU).

PSU staff report the implementation of the state fair hearing decision in TIERS on Form H4807 according to current procedures.;

7422 New Assessment Required by State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

If the hearings officer’s decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Medical Necessity and Level of Care (MN/LOC) Assessment, or Form H6516, Community First Choice Assessment, the state fair hearing is closed, pending the results of the new assessment. Program Support Unit (PSU) staff must notify the applicant, member or authorized representative (AR) 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 AR may appeal the results of the new assessment. If the applicant, member or AR chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, on Form 4800-D, 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 AR 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 STAR+PLUS Home and Community Based Services (HCBS) program 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/LOC Assessment, which results in another MN denial. PSU staff send a notice to the member or AR informing him or her of the MN denial. The member or AR then requests 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 AR 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. 

7423 Request to Withdraw a State Fair Hearing

Revision 19-13; Effective November 5, 2019

An applicant, member or authorized representative (AR) 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 AR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or AR 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 AR 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 AR and must be made to the hearings officer.

If the applicant, member or AR 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 AR 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.