Form 4801, State Fair Hearing Evidence Packet Cover Page

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Documents

Effective Date: 1/2023

Instructions

Updated: 1/2023 

Purpose

To notify an applicant or member who requested a state fair hearing of the documents included in the state fair hearing evidence packet.

Procedure

When to Prepare

Program Support Unit (PSU) staff prepare Form 4801, State Fair Hearing Evidence Packet Cover Page and 4801-S when creating the state fair hearing evidence packet for a Medically Dependent Children Program (MDCP) or STAR+PLUS Home and Community Based Services (HCBS) program applicant or member. PSU staff must mail Form 4801, Form 4801-S and its attachments to the applicant, member, medical consenter, authorized representative (AR) or legally authorized representative (LAR) on the same date PSU staff schedule the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS).

Copies and Transmittal

PSU staff mail the original Form 4801 and 4801-S to the applicant, member, medical consenter, AR, or LAR as applicable. 

Form Retention

Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) is the electronic case record for STAR+PLUS HCBS program and MDCP. Paper copies of Form 4801 and Form 4801-S are not retained. PSU staff dispose of paper copies of Form 4801 and Form 4801-S by following established procedures for destruction of confidential data, as described in the HHS Computer Usage and Information Security Training. PSU staff must upload a copy of Form 4801 and Form 4801-S to the HEART case record on the same date PSU staff schedule the state fair hearing in TIERS.

Supply Source

Form 4801 and Form 4801-S can be found in the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) and STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH).

Detailed Instructions

Upper Left Section

Name and Address — Enter the applicant, member, medical consenter, AR or LAR’s name and mailing address. For STAR Health, this will be the address of the medical consenter provided by the STAR Health MCO. If the AR, LAR or medical consenter’s name is used, the applicant or member’s name must also be included for identification purposes.

Upper Right Section 

Date of Notice — Enter the date PSU staff complete and mail the form to the applicant, member, medical consenter, AR or LAR.

HHSC Staff — Enter the name of the PSU staff.

Office Address and phone number — Enter the office address. Include the street address or post office box, mail code, city, state, ZIP code and direct phone number.

Body of the Form

Program Type — Select “Medically Dependent Children Program (MDCP)” or “STAR+PLUS Home and Community Based Services (HCBS) Program,” as applicable.