Revision 23-4; Effective Aug. 21, 2023

1 Texas Administrative Code (TAC) Section 357.1, Definitions,  states an appeal is a request for a review of an agency action or failure to act that may result in a fair hearing. A Medically Dependent Children Program (MDCP) applicant, member, legally authorized representative (LAR) or medical consenter has the right to request an appeal within 90 days from the effective date of a Texas Health and Human Services Commission (HHSC) action as indicated in 1 TAC Section 357.3,  Authority and Right to Appeal. The appeal request may be verbal or in writing.

A fair hearing is an informal proceeding held before an impartial HHSC hearings officer where an applicant, member, LAR or medical consenter appeals an agency action, as indicated in 1 TAC Section 357 .1. 
 

7201 Timely or Non-timely State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

An applicant, member, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) may request a state fair hearing orally or in writing.

A timely state fair hearing request for a Medically Dependent Children Program (MDCP) eligibility denial is received by Program Support Unit (PSU) staff no later than 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for an MDCP eligibility denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

If a non-timely state fair hearing request is received from the applicant or member, PSU staff create the appeal in the Texas Integrated Eligibility Redesign System (TIERS). If the hearing officer determines there is good cause, the hearing officer will schedule a state fair hearing date. If the hearing officer determines if there is no good cause, the applicant or member is no longer eligible for a state fair hearing.

7210 Entering a State Fair Hearing In TIERS

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive a verbal or written appeal request related to a Medically Dependent Children Program (MDCP) eligibility denial or termination from an: 

• applicant;
• member; 
• legally authorized representative (LAR); or
• medical consenter. 

PSU staff must complete the following activities within two business days from the receipt of all appeal requests, except appeal requests resulting from a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denial:

• create a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• create a fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) following the instructions in Appendix XXI, Creating an Appeal in TIERS.

Note: PSU staff entries in TIERS depend on the issue being appealed. 

TIERS will assign an appeal identification (ID) number when PSU staff complete and submit the fair hearing in TIERS. PSU staff must document the appeal ID number in the HEART case record.

Refer to Section 7213, State Fair Hearing Evidence Packet, for more information on activities PSU staff must complete on the same date as creating the fair hearing in TIERS.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to an MEPD or TW financial eligibility denial. 

7211 Reserved for Future Use

Revision 23-4; Effective Aug. 21, 2023

7212 Generation of the State Fair Hearing Packet

Revision 18-0; Effective September 4, 2018

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 legally authorized representative (LAR), such as Texas Health and Human Services Commission (HHSC), Texas Medicaid & Healthcare Partnership (TMHP), and managed care organization (MCO) staff. 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 mails to the applicant, member or LAR. 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.

7213 State Fair Hearing Evidence Packet

Revision 23-3; Effective May 22, 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 the state fair hearing evidence packet;
• mail the state fair hearing evidence packet to the applicant, member or legally authorized representative (LAR); 
• 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 the State Fair Hearing Evidence Packet to the 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 XVIII, STAR Kids 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. Centralized Representative Unit (CRU) is responsible for creating all fair hearings related to MEPD and TW financial denials.

PSU staff must:

• Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials. 
• Ensure documentation clearly states the state fair hearing is for the Medically Dependent Children Program (MDCP). 

The PSU state fair hearing evidence packet includes the following:

• 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 XVII, MDCP Eligibility TAC;
• Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, as applicable, for members transitioning from MDCP due to turning 21;
• the following documents, as applicable, for medical necessity (MN) denials or terminations:
  • Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants; or
  • Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members; and
  • any written requests for a state fair hearing, first position or advanced placement.

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), CRU or the 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 LAR.

The hearings officer mails Form 4803, Notice of Fair Hearing, to the applicant, member or LAR when the state fair hearings is initially requested. The applicant, member, or LAR may fax or mail evidence to the hearings officer if desired. The applicant, member or LAR obtains the hearings officer’s contact information from Form H4803. The hearings officer shares any evidence submitted by the applicant, member or LAR with HHSC.

7214 Changes to the State Fair Hearing Request Summary

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may learn of changes to an applicant or member’s information after entering the fair hearing into Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must complete the following activities as soon as possible but no later than 10 days from notification of the change:

• verify that a hearings officer has been assigned to the case by checking TIERS;
• complete Form H4800-A,  Fair Hearing Request Summary (Addendum), with the updated information;
• upload Form H4800-A to the Texas Health and Human Services Commission (HHSC) Benefits Portal;
• notify the hearings officer by email. The email to the hearings officer must include the following:
  • an email subject line that reads: Form H4800-A for XX [first letter of the applicant’s or member’s first and last name]
  • applicant or member’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number, as applicable;
  • HHSC State Benefits appeal ID number; 
  • the type of request (i.e., notification of a change); and
  • Form H4800-A;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

PSU staff must include the following on Form H4800-A:

• a clear statement indicating that this is a state fair hearing for Medically Dependent Children Program (MDCP); and
• the appeal ID number assigned by TIERS in the designated field on Form H4800-A.

PSU staff may also email Form H4800-A to the hearings officer if they encounter issues with uploading Form H4800-A to the HHSC Benefits Portal.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to Medicaid for Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denials. 

Delays in uploading documentation may delay the fair hearing or require the fair hearing to be rescheduled.

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

7221 Type of Denials

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff procedures for processing a fair hearing vary based on the denial reason. For example, PSU staff notify the Centralized Representative Unit (CRU) using the Texas Health and Human Services Commission (HHSC) Benefits Portal if the appeal request is a result of a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denial. PSU staff create a fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) for all other denial reasons when the applicant or member requests a fair hearing. 

Refer to the following sections for more information about processing an appeal request for the following denial reasons:

• Section 7221.1,  Medical Necessity Denial by Texas Medicaid & Healthcare Partnership, for a medical necessity (MN) denial reason;
• Section 7221.2,  Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for a MEPD or TW financial eligibility denial reason;
• Section 7221.3,  Supplemental Security Income Denial by the Social Security Administration, for a supplemental security income (SSI) denial reason; or
• Section 7221.4,  Other Denial Reasons, for any other denial reason.
   

7221.1 Medical Necessity Denial by Texas Medicaid & Healthcare Partnership

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities for an appeal request for a medical necessity (MN) denial:

• create the following within two business days from the receipt of the appeal request: 
  • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
    • Note: The HEART case record must remain open until the fair hearing decision is rendered; 
  • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS) following the instructions in Appendix XXI,  Creating an Appeal in TIERS;
• prepare, mail and upload the state fair hearing evidence packet on the same date PSU staff create the fair hearing in TIERS;
• complete Form H4800-A, Fair Hearing Request Summary (Addendum) if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
• maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
• monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision; 
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff do not attend the fair hearing for MN denials or terminations.

Refer to Section 7222.1,  Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information about continuing MDCP benefits during the fair hearing. 
 

7221.2 Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 18-0; Effective September 4, 2018

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). The CRU is required to attend the state fair hearing to represent Medically Dependent Children Program (MDCP) 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 XII, Create an Appeal Task in the HHSC Benefits Portal;
• an email to CRU at the HHSC Access and Eligibility Services (AES) Fair Hearing mailbox that includes:
  • a subject line that reads: MDCP Appeal Request - client’s initials-XX and last 4-digit case number-XXXX;
  • applicant or member name;
  • Medicaid identification (ID) number (if applicable);
  • type of service (MDCP);
  • specific information requesting the MEPD or TW financial 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 financial 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 case open pending the state fair hearing decision;
  • a copy of Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available); 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 H4800, Fair Hearing Request Summary.

Refer to Section 7222.1, Continuation of Medically Dependent Children 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 H4800 and the appeal identification number (ID). Once PSU staff receives the notification, PSU staff upload the notification in HEART and monitor the appeal until the state fair hearing decision is rendered. PSU staff must not put an applicant or member name back on the MDCP 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 MDCP interest list if the denial is sustained.

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

Refer to Section 7500, 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 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities for an appeal request for a supplemental security income (SSI) financial eligibility denial:

• create the following within two business days from the receipt of the appeal request: 
  • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered; and 
  • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS);
• prepare, mail and upload the state fair hearing evidence on the same day PSU staff create the fair hearing in TIERS;
• complete Form H4800-A, Fair Hearing Request Summary (Addendum), if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
• maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
• attend and present the state fair hearing evidence packet during the fair hearing;
• monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision; 
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff attend the fair hearing for SSI denials and terminations. Refer to Section 7232, Presentation of the State Fair Hearing Evidence Packet, for more information about PSU procedures during the fair hearing.

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for SSI terminations. 

7221.4 Other Denial Reasons

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive a fair hearing request for other denial and termination reasons. Other denial reasons include:

• living arrangement is not an allowable setting;
• voluntarily declined services;
• unable to locate the applicant or member;
• failure to obtain physician signature; or
• exceeding the STAR Kids individual service plan (SK-ISP) cost limit.

PSU staff must complete the following activities for an appeal request not related to a denial reason listed in Sections 7221.1, Medical Necessity Denial by Texas Medicaid & Healthcare Partnership, through Section 7221.3, Supplemental Security Income Denial by the Social Security Administration:

• create the following within two business days from the receipt of the appeal request: 
  • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered; and
  • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS);
• prepare, mail and upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal on the same day PSU staff create the fair hearing in TIERS;
• complete Form H4800-A, Fair Hearing Request Summary (Addendum), if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
• maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
• monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision; 
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff do not attend the fair hearing for any other denial reason appeal request except for supplemental security income (SSI) denial reason appeal requests.

Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information about continuing Medically Dependent Children (MDCP) benefits during the fair hearing.

7222 Continuation or Termination of Services

Revision 18-0; Effective September 4, 2018

7222.1 Continuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 23-4; Effective Aug. 21, 2023

Medically Dependent Children Program (MDCP) benefits must continue until the hearings officer issues a decision if the member, legally authorized representative (LAR) or medical consenter files an appeal requesting continued benefits:

• within the adverse action notification period of the MDCP termination; or
• by the effective date of the action pending the fair hearing.

The deadline is whichever date is later.

Continuation of MDCP benefits during a state fair hearing do not apply for supplemental security income (SSI) terminations. 

Refer to Section 6200, Adverse Action Notification Period, for more information about the adverse action notification period.

PSU staff must complete the following activities on the same date PSU staff create a fair hearing in Texas Integrated Eligibility Redesign System (TIERS) or enter an appeal request in the Texas Health and Human Services (HHSC) Benefits Portal for a medical assistance only (MAO) member when it is determined the member may receive continued benefits, as applicable:

• extend the existing STAR Kids individual service plan (SK-ISP) in four calendar month intervals until the fair hearing decision is rendered if the hearings officer’s decision will not be made until after the SK-ISP expiration date. Example: The member’s four-month period would end on April 30, 2023, if the SK-ISP expiration date is Dec. 31, 2022, and the state fair hearing decision date will not be made until after Dec. 31, 2022.
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; 
• document the HEART case record; and
• monitor the case for the receipt of the TIERS alert indicating the hearings officer’s decision.

HHSC continues services pending the fair hearing decision if the fair hearing is initially dismissed and then subsequently reopened and the member, LAR or medical consenter requests continued benefits. The hearings officer will void the prior fair hearing decision if the hearings officer sets a date for a new fair hearing. The member must continue to receive services until the hearings officer renders a new fair hearing decision. 

PSU staff do not mail Form H2065-D, Notification of Managed Care Program Services, to the member, LAR or medical consenter notifying of continued MDCP benefits.

PSU staff must notify the following parties within three business days from the date the member requests a fair hearing with continued benefits within the adverse action notification period or the effective date of action (whichever is later): 

• the managed care organization (MCO) by uploading Form H2067-MC,  Managed Care Programs Communication, to TxMedCentral, notating that the MCO must continue to provide services until the hearings officer renders a decision; and
• for MAO members, email Centralized Representation Unit (CRU) Unit staff at the Texas Health and HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information: 
  • an email subject line that reads: “MDCP Request for Continued Benefits – XX [member’s first and last initials] #### [last four digits of the case number]”;
  • member name;
  • Medicaid identification (ID) number;
  • HHSC Benefits Portal appeal ID number, if available;
  • TIERS case number;
  • type of service (MDCP);
  • reason for termination (e.g., medical necessity denial); and
  • specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD), or Texas Works (TW) financial termination 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 about medical necessity (MN)”.

PSU staff must: 

• upload all applicable documents to the HEART case record; 
• document the HEART case record; and
• monitor the case for the receipt of the TIERS alert indicating the hearings officer’s decision. 

7222.2 Discontinuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 23-3; Effective May 22, 2023

A member’s Medically Dependent Children Program (MDCP) services continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services. The MDCP denial date is the last day of the month of the current STAR Kids individual service plan (SK-ISP) or the last day of the month in which the adverse action notification period ends, whichever is later. Program Support Unit (PSU) staff refer to Section 6200, Adverse Action Notification Period, for more 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 MDCP services during the state fair hearing. 

7230 State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

7231 Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal on the same day PSU staff enter the state fair hearing.

PSU staff must:

• select the Appeals/RFR tab and ensure the appeal was entered in the Texas Integrated Eligibility Redesign System (TIERS);
• 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);  
• select Upload;
• 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 XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record.

PSU staff must refer to Section 7213, State Fair Hearing Packet, for documentation PSU staff must submit as evidence.

PSU staff must correct errors found in the state fair hearing task in TIERS.

PSU staff must correct errors made on: 

• the "Agency Representative" screen in TIERS using the "Maintain Appeals" screen in TIERS; and
• any other screen in TIERS by completing and uploading Form H4800-A, Fair Hearing Request Summary (Addendum), to the HHSC Benefits Portal. 

The "Agency Action Date" cannot be changed.

PSU staff must refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for Medicaid for Elderly and Persons with Disabilities (MEPD) or Texas Works (TW) financial denials.

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 2603, STAR Kids Individual Service Plan (ISP) Narrative.
• Pages 11-15 contain policy from the STAR Kids Handbook (SKH) that relates directly to the issue in question.
• Pages 16-20 contain documents signed by the applicant, member or legally authorized representative (LAR) related to individual rights.
• Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or LAR on March 2."

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

• Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
• Page 2 contains a copy of Appendix XVII, MDCP Eligibility TAC that states the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) 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 Kids Medically Dependent Children Program (MDCP) services to eligible applicants or members. 
• Page 3 contains a copy of the Section 6300.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR Kids MDCP services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) program requirements.
• Page 4 contains Form H2065-D, which was mailed to the applicant, member or LAR 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 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in the Texas Integrated Eligibility Redesign System (TIERS) advising that the hearings officer rendered a decision. The hearings officer sends the written decision to the applicant, member, legally authorized representative (LAR) or medical consenter and copies all individuals entered into the fair hearing in TIERS. This includes PSU staff and the PSU supervisor.

The hearings officer renders the following state fair hearing decisions:

• sustained;
• sustained with instructions; and
• reversed.

The hearings officer issues a: 

• sustained decision when the hearings officer determines the Texas Health and Human Services Commission’s (HHSC’s) action was appropriate per policy and law;
• sustained with instructions decision when the hearings officer determines HHSC’s action was appropriate per policy and law, but new information was provided and more action is required; or 
• reversed decision when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) benefits.

The hearings officer will specify the corrective actions to be taken and a 10-day time frame the completion of the actions if the hearing decision is sustained with instructions or reversed.

Refer to Section 7500,  State Fair Hearing Decision Actions, for actions to take when the hearings officer renders their decision.

Refer to Section 7310,  Action Taken on a State Fair Hearing Decision, for additional requirements PSU staff must implement for supplemental security income (SSI) denial fair hearings.
 

7310 Action Taken on the State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff complete the following activities for an applicant or member’s fair hearing resulting from a supplemental security income (SSI) denial within 10 days from the date of the fair hearing officer’s decision: 

• enter PSU staff actions taken because of the hearings officer’s decision in the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS); or
• complete Form H4807, Action Taken on Hearing Decision, and email it to the hearings officer and the PSU

supervisor notating PSU staff actions taken because of the hearing officer’s decision, if PSU staff is unable to enter the Decision Implementation screen in TIERS.
PSU staff must complete the following activities for an applicant or member’s fair hearing resulting from an SSI denial when PSU staff encounter a delay in implementing the hearings officer’s decision: 

• notify the PSU supervisor; and
• enter the reason for the delay in the Decision Implementation screen in TIERS, noting the begin and end delay dates; or
• complete Form H4807 and email it to hearings officer and the PSU supervisor following Form H4807 instructions if PSU staff are unable to enter the delay in the Decision Implementation screen in TIERS.
   

7510 Sustained State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A sustained fair hearing decision occurs when the hearings officer renders a decision to uphold the Medically Dependent Children Program (MDCP) denial or termination. For example, 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), sustaining the action on appeal. 

7510.1 Sustained State Fair Hearing Decision for Applicants

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain an applicant’s denial:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision sustained the action on appeal;
• close the Community Services Interest List (CSIL) record if the record is open;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, legally authorized representative (LAR) or medical consenter of the sustained termination. 

7510.2 Sustained State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued Medically Dependent Children Program (MDCP) benefits:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
  • hearing decision sustained the action on appeal; and
  • MCO must deliver services through the MDCP termination effective date;
• terminate the STAR Kids individual service plan (SK-ISP) and the Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7511, Sustained Decision – Termination Date;
• close the Community Services Interest List (CSIL) record if the record is open;
• for medical assistance only (MAO) members, email the Centralized Representation Unit (CRU) Unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
  • an email subject line that reads: “Sustained Benefits for MDCP – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”;
  • the member's name;
  • Medicaid identification (ID) number;
  • the type of request (i.e., notification of sustained MDCP benefits); 
  • the type of service (i.e., MDCP);
  • HHSC Benefits Portal appeal ID number;  
    the Texas Integrated Eligibility Redesign System (TIERS) case number;
  • MDCP termination effective date; and
  • the state fair hearing decision.
    • Note: CRU staff will terminate Medicaid eligibility for MAO members.
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member, legally authorized representative (LAR) or medical consenter of the sustained termination.

7510.3 Sustained State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision sustained the action on appeal;
• close the Community Services Interest List (CSIL) record if the record is open;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member, legally authorized representative (LAR) or medical consenter of the sustained termination. 

7511 Sustained Decision – Termination Effective Date

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must adjust the member’s STAR Kids individual service plan (SK-ISP) end date and terminate the SK-ISP per the fair hearings officer’s sustained decision when the member received:

• continued Medically Dependent Children Program (MDCP) benefits during the fair hearing; and
• a sustained fair hearing outcome.

The final termination effective date varies depending on the following: 

• hearings officer’s decision date;
• original SK-ISP date; and
• SK-ISP expiration date as a result of the member receiving continued MDCP benefits during the fair hearing.

See below table for further clarification of each scenario.

Scenario 1: PSU staff must adjust the extended SK-ISP end date back to the historical SK-ISP end date if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision is 30 days or more before the end of the historical SK-ISP end date. 

Scenario 2: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date (the date the order is signed) if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision date is 30 days or less before the end of the historical SK-ISP end date.

Scenario 3: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date if the:

• member received continued MDCP benefits during the fair hearing;
• hearings officer’s decision sustains the termination; and
• hearings officer’s decision date is: 
  • after the end of the SK-ISP in effect when the member filed the state fair hearing; and
    • before the end of the extended SK-ISP date.

7520 Reversed State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A reversed fair hearing decision occurs when the hearings officer determines the Texas Health and Human Services Commission (HHSC) action was not appropriate per policy and law. HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) benefits when the hearings officer issues a reversed fair hearing decision.

7520.1 Reversed State Fair Hearing Decision for Applicants 

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse an applicant’s denial: 

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision reversed the action on appeal;
• reactivate the STAR Kids individual service plan (SK-ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and the Enrollment Form;
• edit the SK-ISP and Enrollment Form dates in the TMHP LTCOP using the effective dates noted in Section 7521,  Reversed Decision – Effective Date; 
• close the Community Services Interest List (CSIL) record if the record is open; and
• follow current policy noted in the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) Section 2000, Medically Dependent Children Program Intake and Initial Application,  for approving Medically Dependent Children Program (MDCP) applicants.

7520.2 Reversed State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who received continued Medically Dependent

Children Program (MDCP) benefits: 

• upload Form H2067-MC, Managed Care Programs Communication , to TxMedCentral notifying the managed care organization (MCO) that the:
  • hearing decision reversed the action on appeal;
  • MDCP benefits must continue as directed in the hearings officer’s decision; and
  • MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• edit the original SK-ISP end date in the TMHP LTCOP to match the historical SK-ISP end date, if applicable;
• update the MDCP Enrollment Form in the TMHP LTCOP, if applicable;
• pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of new SK-ISP in the TMHP LTCOP;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

• edit the new SK-ISP effective date in the TMHP LTCOP using the effective date noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed; 
• close the Community Services Interest List (CSIL) record if the record is open;
• generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
• upload all applicable documents to HEART case record; and
• document and close the HEART case record.

7520.3 Reversed State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits: 

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
• hearing decision reversed the action on appeal;
• MDCP benefits must be reinstated as directed in the hearings officer’s decision; and
• MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
• edit the original SK-ISP and Enrollment Form end date in the TMHP LTCOP to match the historical SK-ISP and Enrollment Form end date, if applicable;
• pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of the new SK-ISP in the TMHP LTCOP;
• upload all applicable documents to the HEART case record; and
• document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

• edit the new SK-ISP and Enrollment Form effective date in the TMHP LTCOP using the effective dates noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed;
• close the Community Services Interest List (CSIL) record if the record is open;
•  generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
• for medical assistance only (MAO) members, email the Enrollment Resolution Services (ERS) Unit staff. The email to the ERS Unit must include the following information:
  • a subject line that reads: “Hearings Officer Decision – STAR Kids MDCP – Reversed Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”; 
  • the member's name;
  • Medicaid identification (ID) number;
  • Health and Human Services Commission (HHSC) Benefits Portal appeal ID number;
  • the Texas Integrated Eligibility Redesign System (TIERS) case number;
  • SK-ISP receipt date;
  • SK-ISP begin date;
  • SK-ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • the state fair hearing decision; and
  • Form H2065-D; 
• for MAO members, email the Centralized Representation Unit (CRU) staff at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
  • a subject line that reads: “Reinstatement of Benefits for MDCP – Appeal ID ####### for XX [first letter of the member's first and last name]”;
  • the member's name;
  • Medicaid ID number;
  • the type of request (i.e., reinstate Medicaid eligibility); 
  • the type of service (i.e., MDCP);
  • HHSC Benefits Portal appeal ID number;
  • the TIERS number;
  • TIERS Medicaid eligibility effective date;
  • the state fair hearing decision; and
  • Form H1746-A, MEPD Referral Cover Sheet; 
• upload all applicable documents to HEART case record; and
• document and close the HEART case record.

7521 Reversed Decision – Effective Date

Revision 23-4; Effective Aug. 21, 2023

The effective begin date for the STAR Kids individual service plan (SK-ISP) for a reversed fair hearing decision depends on if the appellant is an applicant, member with continued Medically Dependent Children Program (MDCP) benefits or member without MDCP continued benefits.

The SK-ISP begin date for an applicant is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer.

The SK-ISP begin date for a member who received continued MDCP benefits is the first day of the month following the end of the SK-ISP in effect when the state fair hearing was filed.

The SK-ISP begin date for a member who did not receive continued MDCP benefits is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer. 

Program Support Unit (PSU) staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with the Central Representation Unit (CRU). 
 

7522 New Assessment Required by State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018

If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed as a result of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) 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 LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must indicate in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800, 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 LAR 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 Medically Dependent Children Program (MDCP) 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 assessment, which results in another MN denial. PSU staff send a notice to the member or LAR informing him or her of the MN denial. The member or LAR then request 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 LAR 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. 

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018

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

If the applicant, member or LAR 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 LAR 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.

Revision 23-4; Effective Aug. 21, 2023

1 Texas Administrative Code (TAC) Section 357.5 indicates the Texas Health and Human Services Commission (HHSC) hearings officer:

• conducts the fair hearing as an informal proceeding, not as a formal court hearing, and is not required to follow the Texas Rules of Evidence or the Texas Rules of Civil Procedure;
• determines whether an applicant, member, legally authorized representative (LAR) or medical consenter requested a fair hearing in a timely manner, or had good cause for failing to do so;
• schedules a pre-hearing conference to resolve issues of procedure, jurisdiction, or representation, if necessary;
• requires the attendance of agency representatives, or witnesses, as needed;
• is prohibited from engaging in ex parte communication, whether verbal or written, with a party or the party's representative or witness relating to matters to be adjudicated; and
• arranges for reasonable accommodations for disclosed disabilities.

During the fair hearing, the HHSC hearing’s officer:

• makes the official recording of the hearing;
• ensures the applicant, member, LAR, medical consenter and HHSC’s rights are protected;
  determines if there is a need for an interpreter;
• limits the number of people in attendance at the hearing if space is limited;
• controls the use by others of cameras, videos or other recording devices;
• administers oaths and affirmations;
• ensures consideration of all relevant points at issue and facts pertinent to the applicant, member, LAR or medical consenter’s situation at the time the action was taken;
• considers the applicant, member, LAR or medical consenter’s changed circumstances, when appropriate and possible;
• requests, receives, and makes part of the record all relevant evidence;
• regulates the conduct and course of the fair hearing to ensure due process and an orderly hearing;
• conducts the hearing in a way that makes the applicant, member, LAR or medical consenter feel most at ease; and
• orders, if determined to be necessary, an independent medical assessment or professional evaluation to be paid for HHSC or HHSC’s designee.

After the hearing, the hearings officer:

• makes a decision based on the evidence presented at the fair hearing;
• determines if HHSC’s action is in compliance with statutes, policies, or procedures;
• allows the applicant, member, LAR or medical consenter to request and receive a copy of the recording at no charge;
• issues a timely written decision, and includes findings of fact, conclusions of law, pertinent statutes, and a final order; and
• ensures compliance, orders HHSC to implement the order within the time limits specified in the relevant federal regulation, monitors compliance with the order, and notifies program management if the order is not implemented.