Revision 22-3; Effective Dec. 1, 2022

The managed care organization (MCO) must develop, implement and maintain a member complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including 42 Code of Federal Regulations (CFR) Section 431.200, 42 CFR Part 438 Subpart F, Grievance System, and the provisions of 1 Texas Administrative Code Chapter 357, relating to Medicaid MCOs.

The MCO's complaint and appeal system must include:

• a complaint process;
• an internal appeal process; and
• access to the Texas Health and Human Services Commission fair hearing process.

7110 Managed Care Organization Complaint Procedures

Revision 22-3; Effective Dec. 1, 2022

The Texas Health and Human Services Commission's (HHSC) STAR Kids Contract, Attachment A, defines a complaint as "an expression of dissatisfaction expressed by a Complainant, orally or in writing to the managed care organization (MCO), about any matter related to the MCO other than an action. As provided by 42 C.F.R. Section 438.400, possible subjects for complaints include the quality of care of services provided, aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Medicaid member’s rights."

The complaint procedure does not apply to situations described in "Appeal Procedures."

When members want to file a complaint, they must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO must provide designated member advocates to:

• assist members in using the complaint system:
• assist members in writing or filing a complaint; and
• monitor the complaint throughout the process until the issue is resolved.

In addition to filing complaints with the MCO, a STAR Kids member may file complaints with the state of Texas. If a STAR Kids member contacts the MCO or any HHSC employee with a complaint about an agency licensed by HHSC, or any other state agency, the member is referred to 800-458-9858 to file a regulatory complaint. If the complaint is initially received by HHSC, HHSC informs the MCO of the complaint.

Members may also contact the HHSC Ombudsman's Managed Care Assistance Team for assistance filing a complaint not related to licensure issues.

• submit through the Online Question or Complaint Form; or
• contact by phone 866-566-8989

7120 Managed Care Organization Internal Appeal Procedures

Revision 22-3; Effective Dec. 1, 2022

The Texas Health and Human Services Commission (HHSC) STAR Kids Contract, Attachment A, defines an appeal as the formal process that a member or his or her authorized representative requests a review of the managed care organization’s (MCO’s) action. An action is:

• the denial or limited authorization of a requested Medicaid service, including the type or level of service;
• the reduction, suspension or termination of a previously authorized service not caused by loss of eligibility;
• denial in whole or in part of payment for service;
• failure to provide services in a timely manner;
• failure of an MCO to act within the time frames set forth in the contract and 42 Code of Federal Regulations (CFR) Section 438.408(b); or
• for a resident of a rural area with only one MCO, the denial of a Medicaid member's request to obtain services outside of the network.

The member may file an internal appeal by contacting the MCO after the procedures specified in the MCO's member handbook. The MCO is contractually required to regard any oral or written expression of dissatisfaction or disagreement related to the actions listed above as an appeal. The MCO must provide a designated member advocate to assist the member in filing an appeal. The advocate must also assist members or authorized representatives by monitoring the appeal throughout the process until the issue is resolved.

During the internal appeal process, the MCO must provide the member or an authorized representative a reasonable opportunity to present evidence and any allegations of fact or law in person, as well as in writing. The MCO must inform the member or the authorized representative of the time available for providing this information.

The MCO must provide the member and his or her authorized representative the opportunity, before and during the appeal process, to examine the member's case file, including medical records and any other documents considered during the appeal process.

As required by 42 CFR Section 438.420, the MCO must continue the individual's benefits pending the outcome of the internal appeal if all the following criteria are met:

• The member or his or her authorized representative files the internal appeal timely, as defined in the STAR Kids contract.
• The appeal involves the termination, suspension or reduction of a previously authorized course of treatment.
• The services were ordered by an authorized provider.
• The original period covered by the original authorization has not expired.
• The member requests an extension of the benefits.

7121 Expedited Managed Care Organization Internal Appeals

Revision 22-3; Effective Dec. 1, 2022

Per 42 Code of Federal Regulations Section 438.410 and STAR Kids Contract, Attachment B-1, Section 8.1.29.3, the managed care organization (MCO) must establish and maintain an expedited review process for service-related internal appeals when the MCO determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking the time for a standard resolution could seriously jeopardize the member’s life or health. The MCO must follow all internal appeal requirements for standard member internal appeals as set forth in the STAR Kids contract, Attachment B-1, Section 8.1.29.2, except where differences are specifically noted. The MCO must accept oral or written requests for expedited internal appeals.

After the MCO receives a request for an expedited internal appeal, the MCO must notify the member or his or her authorized representative of the outcome of the expedited internal appeal request within 72 hours. However, the MCO must complete investigation and resolution of an internal appeal relating to an ongoing emergency or denial of continued hospitalization:

• per the medical or dental immediacy of the case; and
• not later than one business day after receiving the member's request for an expedited internal appeal.

Members must exhaust the MCO’s expedited internal appeal process before making a request for an expedited State Fair Hearing.

Except for an internal appeal relating to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited internal appeal may be extended up to 14 calendar days if the member requests an extension or the MCO shows (to the satisfaction of the Texas Health and Human Services Commission (HHSC), upon HHSC’s request) there is a need for more information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.

If the determination is adverse to the member, the MCO must follow the procedures relating to the notice in the STAR Kids Contract, Attachment B-1, Section 8.1.29.5. The MCO is responsible for notifying the member of his or her right to access a State Fair Hearing from HHSC. The MCO is responsible for providing documentation to the state and the member, indicating how the determination was made, before the HHSC’s fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his or her representative for requesting an expedited internal appeal. The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member’s request.

If the MCO denies a request for expedited resolution of an internal appeal, the MCO must:

• transfer the appeal to the time frame for standard internal resolution; and
• make a reasonable effort to give the member prompt oral notice of the denial, and follow up within two calendar days with a written notice.

Revision 23-4; Effective Dec. 1, 2023

A member can ask for an External Medical Review (EMR) when they disagree with the health plan’s internal appeal decision. An EMR is an optional, extra step the member can take to get an adverse benefit determination reviewed. The EMR is conducted by a third-party Independent Review Organization (IRO) and occurs before the State Fair Hearing.

A standard EMR takes place within 15 calendar days of the request. An expedited EMR takes place within two business days of the request.

When a member requests an EMR with a  State Fair Hearing, the MCO must upload all required State Fair Hearing documentation into the Texas Health and Human Services Commission (HHSC) State Benefits Portal within the following time frames:

• expedited EMR request – within one calendar day of receiving the EMR request from the member, the member’s authorized representative, or the member’s legally authorized representative (LAR), unless received after 3:00 p.m. CST on a Friday, or any calendar day HHSC is closed for business. If the EMR Request is received after 3:00 p.m. CST on Friday, or on a day HHSC is closed for business, the documentation must be uploaded no later than noon the following business day; or
• standard EMR request – no later than three calendar days after receiving the EMR request from the member, the member’s authorized representative, or the member’s LAR.

Only information used to make the MCO internal appeal decision can be uploaded into the HHSC State Benefits Portal for the IRO to review. The IRO will not consider any new information submitted by the MCO or member.

The IRO will conduct the EMR and notify the MCO of the decision to uphold, partially overturn, or overturn the MCO’s internal appeal decision. The IRO can only grant or reinstate the member’s benefits up to the level identified as medically necessary by the member’s physician or as previously authorized before the adverse benefit determination. An EMR request does not change the member’s right to a State Fair Hearing. Regardless of the EMR decision, the member continues to have the right to proceed with the State Fair Hearing. The State Fair Hearing will proceed after the EMR decision unless the member withdraws their request for a State Fair Hearing.

The member may qualify for an expedited EMR with a State Fair Hearing as outlined in STAR Kids Contract, Attachment B-1, Sections 8.1.29.3 and 8.1.29.4. More information can be found in the Uniformed Managed Care Manual (UMCM) 3.21 (PDF) and 3.21.1 (Word).

Revision 22-3; Effective Dec. 1, 2022

If an applicant, member, or legally authorized representative (LAR) wishes to request a State Fair Hearing with the state of Texas regarding a Medically Dependent Children Program (MDCP) waiver eligibility denial, they must contact the Program Support Unit (PSU) as instructed in the denial notification.

In addition to appealing an adverse action not related to eligibility, the MDCP waiver member may also request a State Fair Hearing by contacting PSU.

If an applicant, member, or legally authorized representative (LAR) wishes to request a fair hearing with the managed care organization (MCO) not related to program eligibility they may contact the MCO as instructed on the denial notification.

7310 Program Support Unit Coordination

Revision 22-3; Effective Dec. 1, 2022

When a request for a State Fair Hearing about Medically Dependent Children Program (MDCP) eligibility is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the Texas Health and Human Services Commission Appeals Division within five calendar days from the date of the request. Upon receipt of the fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary. 

Form H4800 records the names, titles, addresses and phone numbers of all persons, or their designees, who should attend the hearing. For appeal issues related to service delivery, enter the names of the designated managed care organization (MCO) staff and the designated backup. 

Depending on the issue being appealed, the following staff must attend:

• MCO (whenever possible, this should be the individual who completed the assessment) and Texas Medicaid & Healthcare Partnership (TMHP) (for medical necessity denials);
• MCO (for denials of individual service plans (ISPs) over the cost ceiling); and
• Medicaid for the Elderly and People with Disabilities (MEPD) (for financial denials).

The MCO must ensure that the appropriate staff members who have firsthand knowledge of the member’s appeal are able to speak and provide relevant information on the case and attend all State Fair Hearings as scheduled.  

7311 Fair Hearings and Appeals Procedures

Revision 22-3; Effective Dec. 1, 2022

If a member requests a State Fair Hearing, the managed care organization (MCO) completes and submits the request via the Texas Integrated Eligibility Redesign System (TIERS) to the appropriate State Fair Hearings office, within five days of the member's request for a State Fair Hearing.

TIERS generates a hearing packet, which includes:

• Form H4803, Notice of Hearing
• Form H4800, Fair Hearing Request Summary

Managed care organizations (MCOs) receive a copy of Forms H4800 and H4803, identifying the hearings officer assigned to the appeal and the date, time, and location of the hearing. 

7312 Evidence Packet

Revision 22-3; Effective Dec. 1, 2022

All related documentation necessary to support the determination on an appeal must be uploaded into the Texas Health and Human Services Commission (HHSC) State Benefits Portal and mailed to the appellant at least 10 business days before the hearing. Each entity involved in the action taken is responsible for preparing its evidence packet and uploading it to the HHSC State Benefits Portal. Within five business days of notification that the State Fair Hearing is set, the MCO will prepare an evidence packet for submission to the HHSC State Fair Hearings staff and send a copy of the packet to the member. All documentation must be neatly and logically organized, and all pages numbered.

The following are examples of documentation that may be submitted as evidence and the entity responsible for uploading that information to the HHSC State Benefits Portal:

• Managed care organization (MCO):
  • MCO policy handbook, STAR Kids Handbook or STAR Kids contract and STAR Kids Managed Care Manual; 
  • summary of events;
  • other documentation supportive of the determination, such as documentation of phone calls and visit summaries; and
  • copies of the signed Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and all relevant attachments;
• Medicaid for the Elderly and People with Disabilities Centralized Representation Unit:
  • documentation supportive of the financial determination, including official documentation forms and phone calls; and
  • a copy of the original signed denial form;
• Texas Medicaid & Healthcare Partnership (TMHP):
  • a copy of the STAR Kids Screening and Assessment Instrument (SK-SAI); and
  • other documentation supporting the determination; and
• Program Support Unit: Refer to procedures outlined in the Program support Unit Operational Handbook, Section 7000, Applicant or Member Complaints and State Fair Hearings.

7320 Additional State Fair Hearing Requirements and Information

Revision 22-3; Effective Dec. 1, 2022

7321 Presentation of the Evidence Packet

Revision 22-3; Effective Dec. 1, 2022

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The managed care organization (MCO) receives a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time, and location of the hearing. 

Documentation contained in the evidence packet is not considered in the hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, the agency or MCO representative must present the packet, ask that it be admitted as evidence, and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the 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 that relates directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant on March 2, 2016."

The hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the hearings officer explains the reasons for excluding the material. Any documents admitted by the hearings officer are considered when a decision is rendered.

7322 Hearing Decision

Revision 22-3; Effective Dec. 1, 2022 

After the hearing, the hearings officer sends a hearing decision to the appellant and copies to individuals listed on Form H4800, Fair Hearing Request Summary. 

If the determination on appeal is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. 

Revision 22-3; Effective Dec. 1, 2022

7410 Action Taken on the Hearing Decision

Revision 22-3; Effective Dec. 1, 2022

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken. Managed care organizations (MCOs) can retrieve the information on the Texas Health and Human Services Commission (HHSC) State Benefits Portal.

7411 State Fair Hearing Reversal of Denial

Revision 22-3; Effective Dec. 1, 2022

If the State Fair Hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the managed care organization (MCO) appeal was pending, the MCO must authorize or provide the disputed services as expeditiously as the member’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination. If the State Fair Hearing officer reverses a decision to deny authorization of services and the member received the disputed services while the appeal was pending, the MCO is responsible for the payment of services.

If the State Fair Hearing officer reverses an MCO's denial of a prior authorization for a durable medical equipment (DME) or DME service after the member has enrolled with a second MCO, the original MCO must pay for the DME service or equipment from the date it denied the authorization until the date the member enrolled with the second MCO. In the case of custom DME, the original MCO must pay for the custom DME if the denial is reversed.

Revision 22-3; Effective Dec. 1, 2022

If the State Fair Hearing is pending, and the member has timely requested continuation of benefits, the benefits must be continued until:

• the member withdraws the request for State Fair Hearing; or
• a State Fair Hearing officer issues a hearing decision adverse to the member. 

See Section 7400, Post Hearing Actions, for information on how to proceed following receipt of the State Fair Hearing decision.

7510 Continuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 23-3; Effective July 21, 2023

Medically Dependent Children Program (MDCP) waiver services must continue until the hearings officer issues a decision about the State Fair Hearing of an active MDCP waiver member, if the request is for a continuation of benefits was timely filed. Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the request for a continuation of benefits within three business days by posting Form H2067-MC, Managed Care Programs Communication, to the MCO via MCOHub.

If the member has timely requested continued benefits, MDCP waiver services must continue to be provided until the hearings officer renders a decision. The PSU includes this information on Form H2067-MC posted on MCOHub.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, the current ISP will be extended for four calendar months or until the outcome of the state appeal is determined. PSU staff do not mail Form H2065-D, Notification of Managed Care Program Services, to the member notifying them of continued eligibility related to the reassessment action taken to continue services until the hearings officer renders a State Fair Hearing decision. 

If a State Fair Hearing is initially dismissed and then re-opened, the PSU staff continues or restarts services pending the decision outcome, if the member has timely requested continued services. When the hearings officer sets a date for a new State Fair Hearing this voids the prior State Fair Hearing decision.

7520 Discontinuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 23-3; Effective July 21, 2023

If the member does not timely request continuation of benefits, Medically Dependent Children Program (MDCP) waiver services continue until the effective date of denial notated on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). Program Support Unit (PSU) staff must process according to the following:

• For Medical Assistance Only (MAO)-eligible members, Form H2065-D is posted to MCOHub to inform the managed care organization (MCO) that MDCP waiver services will be terminated effective the day after the date noted on Form H2065-D. For Supplemental Security Income (SSI)-eligible members, Form H2067-MC is posted by PSU staff to MCOHub to inform the MCO MDCP waiver services will be terminated effective the day after the date noted on Form H2065-D.

Even if a member loses eligibility for MDCP, SSI-eligible members are still enrolled in a STAR Kids MCO and are still eligible for state plan services, which include acute care and long-term services and supports, such as personal care services, day activity and health services, and Community First Choice Services.
 

Revision 22-3; Effective Dec. 1, 2022

7610 Sustained State Fair Hearing Decisions

Revision 22-3; Effective Dec. 1, 2022

When the hearings officer’s decision sustains the denial of Medically Dependent Children Program (MDCP) waiver services, the written decision is mailed to the applicant, member, or their legally authorized representative (LAR). Copies are sent to all witnesses listed on Form H4800, Fair Hearing Request Summary.

7611 Sustained Decisions – Termination Effective Dates

Revision 22-4; Effective Dec. 1, 2022

When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the State Fair Hearing decision is known, the Medically Dependent Children Program (MDCP) waiver termination effective date varies depending on the following circumstances.

• In cases where the hearings officer's decision is 30 calendar days or more before the end of the individual service plan (ISP) in effect when the State Fair Hearing was filed, MDCP waiver termination is effective at the end of the ISP in effect at the time the State Fair Hearing was filed. See Example 1.
• When the hearings officer's decision date is less than 30 calendar 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 calendar days from the hearings officer's decision date (the date the order is signed). See Example 2.
• 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 appeal decision was made, the termination effective date is the end of the month that is 30 calendar days from the hearings officer's decision date. See Example 3.
• If the hearings officer assigns a specific medical necessity (MN) 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 the hearings officer identified as the expiration month. See Example 4.
• When the hearings officer assigns a specific MN 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. See Example 5.
• If the hearings officer assigns a specific MN expiration date that is before the end of the MN in effect when the State Fair Hearing was filed, the termination effective date is the end of the month of the original MN expiration date. See Example 6.

Examples

Example	Conditions	Original MN/ISP Expiration Date	New Expiration Date	Hearings Officer Decision Date	Final MN/ISP Expiration Date
1	Hearings officer decision is more than 30 days from the original expiration date.	1/31/22	5/31/22	11/2/21	1/31/22
2	Hearings officer decision is less than 30 days from the original expiration date.	1/31/22	5/31/22	1/15/22	2/28/22
3	Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date.	1/31/22	5/31/22	2/15/22	3/31/22
4	Hearings officer decision assigns a specific expiration date.	1/31/22	5/31/22	Hearings officer decision was for MN to expire on 2/15/16.	2/29/22
5	Hearings officer decision assigns a specific expiration date that occurs in the future.	1/31/22	5/31/22	Hearings officer decision was for MN to expire on 2/29/16.	2/29/22
6	Hearings officer decision assigns a specific expiration date that occurred in the past.	1/31/22	5/31/22	Hearings officer decision was for MN to expire on 12/31/21.	1/31/22

7612 Reversed Appeal Decisions

Revision 23-4; Effective Dec. 1, 2023

Within two business days from the hearings officer’s decision to reverse an applicant’s or member’s Medically Dependent Children Program (MDCP) denial of the program, Program Support Unit (PSU) staff will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral:  

• Notifying the managed care organization (MCO) of the hearings officer’s decision to reverse the denial of MDCP;
• Advising the MCO that MDCP services are to continue as directed in the hearings officer’s decision; and
• Requesting the MCO to submit the STAR Kids individual service plan (SK-ISP).

Within two business days from the receipt of Form H2067-MC from PSU staff, the MCO will provide PSU staff with the SK-ISP by uploading to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

7613 Reversed Decisions – Effective Dates

Revision 22-3 Effective Dec. 1, 2022

When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) waiver eligibility, the MDCP waiver effective date for:

• members - reassessment is one day after the end of the individual service plan in effect when the state fair hearing was filed; and
• applicants - MDCP waiver denied at initial application is the first of the month following the hearings officer's decision.

When a fair hearing decision reverses a Program Support Unit (PSU) action but PSU staff cannot implement the fair hearing decision within the required time frame, PSU staff must complete the Implementation Delays screen in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation.

7620 New Assessment Required by Fair Hearing Decision

Revision 22-3; Effective Dec. 1, 2022

If the hearings officer’s final decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI), the hearing is closed as a result of this ruling. Program Support Unit (PSU) staff must notify the member 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 member may appeal the results of the new assessment. If the member chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, of Form H4800, Fair Hearing Request Summary, that the new assessment was ordered from a previous fair hearing decision.

If the member requests a State Fair Hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second fair hearing decision is implemented. For example, a Medically Dependent Children Program (MDCP) waiver member is denied MN at an annual reassessment and requests a fair hearing and services are continued. The MCO would continue services at the level the member was receiving before 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 informing him or her of the MN denial. The member then requests another fair hearing and services are continued pending the second fair hearing decision. The MCO continues services at the same level services were continued before the first fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member requests a fair hearing due to the lower RUG level, the MCO continues services at the same level services were continued before the first fair hearing.

7630 Request to Withdraw a State Fair Hearing

Revision 22-3; Effective Dec. 1, 2022

An appellant or appellant representative must request to withdraw a State Fair Hearing by sending a notice to the hearings office. The appellant or appellant representative may request withdraw of the State Fair Hearing orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing.

If the individual requesting to withdraw contacts Program Support Unit (PSU) staff, PSU staff must advise them the request to withdraw the State Fair Hearing must be provided directly to the hearings office. If PSU staff receive a written request to withdraw, PSU staff must forward this written request to the hearings office. All requests to withdraw the hearing must originate from the applicant, member or LAR, and must be made to the hearings office.

If the request to withdraw a State Fair Hearing is within five business days of the fair hearing date, the hearings officer will notify PSU by phone or email and open the conference line to inform participants of the cancellation. If the request to withdraw a State Fair Hearing is more than five business days before the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written notice to participants informing them of the fair hearing cancellation.

Revision 22-3; Effective Dec. 1, 2022

The Texas Health and Human Services Commission (HHSC) hearings officer:

• notifies all people listed on Form H4800, Fair Hearing Request Summary, of the date, time and location of the hearing;
• prepares a final order disposing of a case through withdrawal
• sends copies of final order to the appellant and Program Support Unit (PSU) upon written notification from the appellant to withdraw a state appeal;
• conducts the hearing;
• considers all testimony and exhibits;
• uses the Texas Medicaid & Healthcare Partnership (TMHP) nurse to determine if any new medical information introduced at the hearing meets the medical necessity (MN) criteria for nursing facility care;
• reserves the right to hold a hearing record open after a State Fair Hearing to get more information;
• submits a written request for medical review to TMHP for all new medical information presented at a hearing in situations where the TMHP nurse determines the new medical information presented does not meet the MN criteria;
• renders a decision; and
• sends a written copy of all hearing decisions to the member or applicant, TMHP and the PSU staff within five days of making the decision.

Administrative review of any hearings officer's decision provided in the fair hearings rules must be initiated by the appellant (applicant, member or legally authorized representative). Program staff may disagree with the decision. However, the hearings officer's decision is final. Program staff submit disagreements on policy or legal issues to the regional attorney.

Revision 23-3; Effective July 21, 2023

When managed care organization (MCO) staff enter fair hearing requests in the Texas Integrated Eligibility Redesign System (TIERS), as outlined in the policy below, use the following entries per the Community First Choice (CFC) level of care (LOC) denial being appealed:

• For Medical Necessity (MN/LOC) fair hearing requests:
  • Program: Community Care
  • Type of Assistance (TOA): Community First Choice
  • Issue Code: 57 - Medical Necessity
• For intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) LOC or institutions for mental diseases (IMD) LOC fair hearing requests:
  • Program: Community Care
  • TOA: Community First Choice
  • Issue Code: 99 - Other (Only use this code in rare instances when there is not a more appropriate code)

STAR Kids Screening and Assessment Instrument (SK-SAI) Denials for Initial or Reassessment Eligibility

As part of the CFC eligibility determination process, the MCO is responsible for completing the SK-SAI assessment to determine MN/LOC. The MCO then submits the SK-SAI assessment to the Texas Medicaid and Healthcare Partnership (TMHP) for approval of the MN/LOC determination. Based on TMHP's decision, the following occurs:

• If TMHP approves MN on the initial or reassessment SK SAI:
  • TMHP notifies the MCO that the member meets medical necessity criteria; and
  • the MCO authorizes CFC services.
• If TMHP denies MN on an initial or reassessment SK-SAI assessment, TMHP notifies the MCO the member does not meet MN. The MCO must follow appeal procedures outlined in the UMCM and take the following action based on the member's situation:
  • For MN denials when the member is not requesting or receiving MDCP program services, the MCO sends the member a denial notice with fair hearing rights. The MCO must include the required elements in the notice. This information will be incorporated in requirements outlined in the Uniform Managed Care Manual. If the member requests a fair hearing, the MCO must enter the fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) and attend the fair hearing. TMHP staff is also required to attend the fair hearing because TMHP is the entity making the LOC decision.

For MN denials when the member is requesting or receiving CFC services and MDCP program services, the MCO must post Form H2067-MC, Managed Care Programs Communication, to MCOHub within two business days of receiving the notice from TMHP (and when the assessment is in MN denied status). This is to notify PSU of the denial and that the member requested or is receiving both MDCP and CFC services. PSU sends the member a denial notice (Form H2065-D, Notification of Managed Care Program Services) for MDCP with fair hearing rights. The notice instructs the member to contact PSU staff to request a State Fair Hearing. If a member makes this request, PSU:

• enters the fair hearing in TIERS within five days; and
• identifies TMHP as the agency representative.

The MCO also attends the fair hearing as the agency witness. The local intellectual and developmental disability authority (LIDDA) or local mental health authority (LMHA) may also be required to attend as an agency representative for State Fair Hearings. If the member requests a timely fair hearing at reassessment and requests continued benefits, the MCO continues services pending the outcome of the fair hearing.