Revision 13-2; Effective June 1, 2013
If an individual is dissatisfied with HHSC's decision concerning his eligibility for any MEPD program, including Medicaid Savings Programs, the individual has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.
Individuals whose medical assistance is denied because of an SSA decision should file an appeal with the appropriate SSA office.
Note: If an individual submits an application during the time the continued benefits are being processed, the application must be processed as normal. See Chapters B-2300, Eligibility Determination, B-3200, Application Process, and B-6400, Processing Deadlines.
If an applicant/recipient requests a fair hearing, the burden of proof to uphold HHSC's decision rests with HHSC. The hearing officer is a neutral party and is restricted by law from presenting HHSC's case.
Form H4800, Fair Hearing Request Summary, provides a space for the names of HHSC's representative and supervisor. The supervisor is responsible for ensuring that either the HHSC representative participates in the hearing or that a back-up person is assigned. Additionally, the supervisor should ensure that the designated representative is sufficiently prepared and knowledgeable of the case to represent HHSC during the fair hearing process.
The hearing officer has the responsibility of setting the date and time of the hearing. In those program areas where Form H4800 may be completed by someone other than agency staff (contracted case management, DADS representatives, etc.), it is important that the hearing officer be given the name(s) of those individuals who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H3800-A, Fair Hearing Request Summary (Addendum), Item 3, "Additional Information."
In those program areas where Form H4800 is completed by HHSC staff but someone other than, or in addition to, HHSC staff will appear (Attorney General's Office staff, Workforce Commission staff, home health nurses, nursing facility staff, etc.), the person completing Form H4800 is responsible for providing the hearing officer with the name(s) of those individuals who are to be notified of the date and time of the hearing. If there is not sufficient space on Form H4800 to provide this information, list the name(s) on Form H4800-A, Item 3, " Additional Information."
Applicants/recipients receiving MEPD programs are perceived by HHSC as essentially honest and entitled to the same protection under the law as all other individuals. When potential fraud is indicated, the allegations must be investigated.
HHSC also endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other individuals. However, if there is an indication of potential fraud, the allegations must be investigated.
The Office of Inspector General (OIG) investigates waste, abuse and fraud in all health and human services programs in Texas. Any state employee or private citizen may report waste, abuse and fraud to the OIG.
HHSC staff, concerned citizens, providers (for example, doctors, dentists, counselors, etc.), Medicaid applicants/recipients and others can help prevent cases of waste, abuse and fraud by notifying OIG.
If applicant/recipient or provider waste, abuse or fraud is suspected in the Medicaid system, complete the OIG's online complaint form, which is available at: https://oig.hhsc.state.tx.us/wafrep/.
If access to the Internet is not available, contact the fraud hotline at 800-436-6184 or mail the complaint to:
Texas Health and Human Services Commission
Office of Inspector General
Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200