Revision 19-13; Effective November 5, 2019

 

 

7100 MCO Procedures

Revision 19-13; Effective November 5, 2019

 

The managed care organization (MCO) must develop, implement and maintain a complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including Title 42 Code of Federal Regulations (CFR) §431 Subpart E; Title 42 CFR Part 438, Subpart F.

If an MCO makes a benefit determination adverse to the member, the member must exhaust the MCO internal appeal system prior to requesting a state fair hearing. If the Texas Health and Human Services Commission (HHSC) denies a member’s Medicaid or program eligibility, the member does not exhaust the MCO internal appeal system, as the MCO did not make the determination. Instead, the member requests a state fair hearing to appeal the HHSC decision.

Refer to Section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, for PSU staff responsibilities related to state fair hearings.

 

7110 MCO Complaint Procedures

Revision 19-13; Effective November 5, 2019

 

The Texas Health and Human Services Commission (HHSC) uses the term “complaint” to describe a grievance. Title 42 Code of Federal Regulations (CFR) §438.400(b)(7) defines a grievance as, “an expression of dissatisfaction about any matter other than an adverse benefit determination.” This definition also notes grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a managed care organization (MCO) service provider, or failure to respect the member’s rights regardless of whether remedial action is requested. Grievance includes a member’s right to dispute an extension of time proposed by the MCO to make an authorization decision.

If the member, authorized representative (AR), or guardian wants to file a complaint, he or she must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO provides a designated member advocate to:

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

If the member is not satisfied with the outcome of the MCO complaint process or the complaint is not resolved within 30 days, the member may:

  • contact the HHSC Ombudsman's Managed Care Assistance Team at 866-566-8989 for assistance filing a complaint; or
  • send a written request to HHSC to investigate the complaint. The request is sent:
    • by mail to Texas Health and Human Services Commission Managed Care Compliance and Operations (MCCO) Unit – STAR+PLUS, 4900 North Lamar Blvd., Mail Code H-320, Austin, TX 78751, or
    • by email to HPM_Complaints@hhsc.state.tx.us.

 

7120 MCO Internal Appeal Procedures

Revision 19-13; Effective November 5, 2019

 

In managed care, Title 42 Code of Federal Regulations (CFR), §438.400(b)(7) defines an “appeal” as a review of a managed care organization (MCO) action, also called an adverse benefit determination. An adverse benefit determination is:

  • a denial or limited authorization of a requested Medicaid service, including the type or level of service;
  • a reduction, suspension or termination of a previously authorized service not caused by loss of eligibility;
  • a denial in whole or in part of payment for service;
  • a failure to provide services in a timely manner; or
  • a failure of an MCO to act within the time frames set forth in the contract and Title 42 CFR §438.408(b).

If the member, authorized representative (AR) or guardian request to file an MCO internal appeal of an adverse benefit determination, the member must file an appeal by contacting the MCO following the procedures specified in the MCO's member handbook or on the MCO’s notice of action. The member must request an MCO internal appeal no later than 90 days from the date of the MCO’s action. The MCO is required to regard any oral or written expression of dissatisfaction or disagreement related to an adverse benefit determination as a request to file an MCO internal appeal. The MCO must provide a designated member advocate to assist the member in filing an MCO internal appeal. The advocate must also assist the member or AR by monitoring the MCO internal appeal throughout the process until the issue is resolved.

To ensure the member is provided the full 10-day adverse action period, the MCO must mail the adverse determination document no later than 10 business days prior the date the adverse action is to occur.

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

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

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

  • MCO internal appeal is filed by the effective date of action;
  • MCO internal appeal involves termination, suspension or reduction of a previously authorized course of treatment;
  • services were ordered by an authorized provider;
  • period covered by the original authorization has not expired; and
  • member or AR requests continued benefits.

A member must request continued benefits no later than 10 days from the date of the MCO’s notice or date of the MCO’s proposed action.  

 

7121 Expedited MCO Internal Appeals

Revision 19-13; Effective November 5, 2019

 

In accordance with Title 42 Code of Federal Regulations (CFR) §438.410, the managed care organization (MCO) must establish and maintain an expedited review process for an adverse benefit determination 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 the time for a standard MCO internal appeal could seriously jeopardize the member’s life or health. The MCO must follow all MCO internal appeal requirements for standard MCO internal appeals as set forth in the CFR. The MCO must accept oral or written requests for expedited MCO internal appeals.

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

  • in accordance with the medical or dental immediacy of the case; and
  • no later than one business day after receiving the member's request for an expedited MCO internal appeal.

The member must exhaust the expedited MCO internal appeal process before making a request for an expedited state fair hearing.

Except for an MCO internal appeal related to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited MCO internal appeal may be extended up to 14 days if the member requests an extension or the MCO shows (to the satisfaction of the Health and Human Services Commission (HHSC), upon HHSC’s request) there is a need for additional 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 MCO internal appeal determination is adverse to the member, the MCO must follow the procedures relating to the notice in the Uniform Managed Care Contract (UMCC) Attachment B-1, Section 8.2.6.5. The MCO is responsible for notifying the member of his or her right to access an expedited state fair hearing. The MCO is also responsible for providing documentation to HHSC and the member, indicating how the determination was made, prior to HHSC’s expedited state fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member, AR or provider for requesting an expedited MCO internal appeal or an expedited state fair hearing. The MCO must ensure punitive action is not taken against a provider who requests an expedited MCO internal appeal or supports a member’s request.

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

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

 

7122 Request for a State Fair Hearing after Exhausting MCO Internal Appeals

Revision 19-13; Effective November 5, 2019

 

An applicant, member, authorized representative (AR) or medical consenter may request a state fair hearing only after exhausting the managed care organization (MCO) internal appeal process for service reduction or denial.

The applicant, member, AR or medical consenter must request a state fair hearing no later than 120 days from the date of the expedited MCO internal appeal.

If an MCO fails to adhere to the notice and timing requirements in Title 42 Code of Federal Regulations (CFR) §438.408, the applicant, member or AR is deemed to have exhausted the MCO’s internal appeal process and may initiate a state fair hearing.

 

7200 State Fair Hearing Procedures for STAR+PLUS HCBS Program

Revision 19-13; Effective November 5, 2019

 

 

 

7210 Timely or Non-timely State Fair Hearing Request

Revision 19-13; Effective November 5, 2019

 

Only an applicant, member, guardian or authorized representative (AR) may request a state fair hearing. The applicant, member or AR may request a state fair hearing orally or in writing.

A timely state fair hearing request for a STAR+PLUS Home and Community Based Services (HCBS) program 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 a STAR+PLUS HCBS program 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 hearings officer determines there is good cause, the hearings officer will schedule a state fair hearing. If the hearings officer determines there is no good cause for a non-timely request for a state fair hearing, the applicant or member is not eligible for a state fair hearing.

 

7211 PSU Staff Procedures for Completing Form 4800-D

Revision 19-13; Effective November 5, 2019

 

Program Support Unit (PSU) staff may receive a request for a state fair hearing related to STAR+PLUS Home and Community Based Services (HCBS) program eligibility from an applicant, member, guardian, or authorized representative (AR) orally or in writing. When a state fair hearing request is received, PSU staff must create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, within five days from the date of the request.

Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

Upon receipt of the state fair hearing request, PSU staff complete Form 4800-D, Fair Hearing Request Summary. PSU staff send Form 4800-D to the data entry representative (DER) and DER supervisor within three days of the request for a state fair hearing. The three-day time frame allows the DER two days to enter the information on Form 4800-D in TIERS.

PSU staff must use Form 4800-D to record the names of all persons who should attend the state fair hearing.

Depending on the issue being appealed, PSU staff must enter the following staff on Form 4800-D:

  • For medical necessity/level of care (MN/LOC) denial by Texas Medicaid & Healthcare Partnership (TMHP):
    • TMHP representative as the Agency Representative;
    • TMHP supervisor as the Agency Supervisor;
    • MCO representative and MCO supervisor as the Agency Witness; and
    • PSU staff and PSU supervisor as the Observer.
  • For Supplemental Security Income (SSI) denial by Social Security Administration (SSA):
    • PSU staff as the Agency Representative;
    • PSU supervisor as the Agency Supervisor;
    • MCO representative and MCO supervisor as the Agency Witness; and
    • no Observer may be listed unless otherwise specified (e.g., a family member).
  • For other denial reasons (excluding MEPD or TW financial denials):
    • MCO representative as the Agency Representative;
    • MCO supervisor as the Agency Supervisor;
    • MCO representative as the Other Participants; and
    • PSU staff and PSU supervisor as the Observer.

PSU staff should contact the MCO if there is any doubt as to who should be listed on Form 4800-D.

When PSU staff complete Form 4800-D, all questions in Section 3, Appellant Details Programs, must be answered. In Subsection D, Summary of Agency Action and Citation, PSU staff must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works (TW) programs. PSU staff must indicate the individual service plan (ISP) begin and end dates, as applicable, in Subsection D.

Refer to Form 4800-D instructions for more specific directions for form completion and transmittal.

 

7212 DER Procedures for Entering State Fair Hearing Request

Revision 19-13; Effective November 5, 2019

 

When the data entry representative (DER) receives Form 4800-D, Fair Hearing Request Summary, from Program Support Unit (PSU) staff, the DER creates a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to document the state fair hearing request. The HEART case record and Community Services Interest List (CSIL) record are to remain open until a state fair hearing decision is rendered.

Within two business days of receipt of Form 4800-D, the DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS). The DER must use the Manage Office Resources (MOR) search function in TIERS when adding PSU, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP), or Texas Health and Human Services Commission (HHSC) representatives as participants. When entry of all information is complete, TIERS assigns the appeal identification (ID) number. The DER sends a copy of the TIERS generated Form H4800, Fair Hearing Request Summary, to PSU staff and uploads it to the HEART case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

 

7213 Generation of the State Fair Hearing Packet

Revision 19-13; Effective November 5, 2019

 

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 authorized representative (AR), such as Texas Health and Human Services Commission (HHSC), the managed care organization (MCO) or Texas Medicaid & Healthcare Partnership (TMHP). A partial state fair hearing packet includes:

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 sends to the applicant, member or AR. A full state fair hearing packet includes:

  • Form H4800;
  • Form H4803;
  • Form H4805, Fair Hearing Procedures; and
  • Form H4806, Request for Another Appointment - Request to Withdraw.

 

7214 State Fair Hearing Packet

Revision 19-13; Effective November 5, 2019

 

Within 10 days, each entity involved in the state fair hearing is responsible for preparing its state fair hearing packet, uploading documents to the Texas Health and Human Services Commission (HHSC) Benefits portal, and mailing documents to the applicant, member or authorized representative (AR). Refer to Section 7231, Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal, for uploading instructions. PSU staff must ensure documentation on Form 4800-D, Fair Hearing Request Summary, clearly states this is a state fair hearing for the STAR+PLUS Home and Community Based Services (HCBS) program. It is crucial that all state fair hearing packets are complete, organized and all pages are numbered to support the agency’s action on appeal.

The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits portal related to Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

The following are examples of documentation that must be submitted as evidence and the entity responsible for uploading information in the HHSC Benefits portal and mailing documents to the applicant, member or AR:

  • Managed Care Organization (MCO):
    • a copy of the notice of action;
    • relevant sections of the MCO policy handbook, STAR+PLUS Handbook, other state or federal rules or regulations, and/or Uniform Managed Care Contract (UMCC) or Uniform Managed Care Manual (UMCM);
    • summary of events;
    • other supporting documentation of the appeal determination, such as documentation of telephone calls, visit summaries, etc.;
    • a copy of Form H1700-1, Individual Service Plan (Pg. 1), a copy of the signed Form H1700-2, Individual Service Plan (Pg. 2), and all relevant attachments; and
    • a copy of Form H2065-D, Notification of Managed Care Program Services, if applicable.
  • PSU:
    • For Supplemental Security Income (SSI) denials:
      • a copy of Form H4803, Notice of Hearing, as a coversheet;
      • a copy of the citation from Title 1 Texas Administrative Code (TAC) §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
      • a copy of Section 3632.4, Denial or Termination of Financial Eligibility, as referenced in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language; and
      • a copy of Form H2065-D.
    • For medical necessity (MN) denials:
      • a copy of Form H2065-D; and
      • a copy of Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment;
      • a copy of the citation from Title 1 TAC §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
      • a copy of the citation from Title 40 TAC §19.2401; and
      • a copy of Section 3632.5, Denial or Termination of MN/LOC Assessment, as referenced in Appendix IV.
  • CRU:
    • relevant sections of the MEPD Handbook, STAR+PLUS Handbook, other state or federal rules or regulation;
    • documentation supportive of the financial determination, including official documentation forms, telephone calls, etc.; and
    • a copy of Form H2065-D.
  • Texas Medicaid & Healthcare Partnership (TMHP):
    • relevant sections of the TAC, other state or federal rules or regulations;
    • a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment;
    • a copy of Form H2065-D; and
    • other documentation supporting the determination.

If an applicant, member or AR wants to submit evidence for the state fair hearing, the applicant, member or AR should fax or mail the evidence to the hearings officer. The hearings officer’s contact information is listed on Form H4803. Any evidence received from an applicant, member or AR is shared with the HHSC.

 

7215 Changes to the State Fair Hearing Request Summary

Revision 19-13; Effective November 5, 2019

 

After the data entry representative (DER) has added information from Form 4800-D, Fair Hearing Request Summary, in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, Program Support Unit (PSU) staff may learn of subsequent changes such as change of address. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials. When subsequent changes occur, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the DER who will check TIERS to identify if a hearings officer has been assigned to the case. The DER must ensure documentation on Form H4800-A clearly states this is a state fair hearing for the STAR+PLUS Home and Community Based Services (HCBS) program. The appeal identification (ID) number assigned by TIERS must be documented in the designated space on Form H4800-A.

If a hearings officer is assigned, the DER must upload Form H4800-A in the Texas Health and Human Services Commission (HHSC) Benefits portal as soon as possible, but no later than 10 days of becoming aware of the change.

Delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.

 

7220 Processing a State Fair Hearing Request

Revision 19-13; Effective November 5, 2019

 

 

 

7221 Type of Denials

Revision 19-13; Effective November 5, 2019


An applicant, member, guardian or authorized representative (AR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member or AR requests a state fair hearing for program denials. PSU staff notify the Centralized Representative Unit (CRU) if it is a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial using the Texas Health and Human Services Commission (HHSC) Benefits portal. PSU staff create all other state fair hearing request in TIERS. The method in which the state fair hearing is requested depends on the action being appealed. PSU staff must determine if the state fair hearing action is:

  • a medical necessity (MN) denial (Refer to Section 7221.1, Medical Necessity Denial by TMHP) below;
  • a financial denial by MEPD or TW (Refer to Section 7221.2, Financial Denial by MEPD or TW);  
  • a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA) (Refer to Section 7221.3, SSI Denial by the SSA; or
  • for any other denial reasons (Refer to Section 7221.4, Other Denial Reasons).

 

7221.1 Medical Necessity Denial by TMHP

Revision 19-13; Effective November 5, 2019

 

If the action is related to a medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP), the managed care organization (MCO) and TMHP representatives are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff upload Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available), to the Texas Health and Human Services Commission (HHSC) Benefits portal to allow the TMHP representative to include Form H2065-D in TMHP’s evidence packet. PSU staff do not attend state fair hearings for MN denials.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the TMHP representative and TMHP supervisor as the Agency Representative and Agency Representative Supervisor.

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

  • TMHP representative as the Agency Representative;
  • TMHP supervisor as the Agency Representative Supervisor;
  • MCO representative and MCO supervisor as the Agency Witness; and
  • PSU staff and PSU supervisor as the Observer.

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the Observer will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an MN, on the Agency Representative field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down menu.

When Form 4800-D is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the STAR+PLUS HCBS program interest list while an MN denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the MN denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.

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

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.2 Financial Denial by MEPD or TW

Revision 19-13; Effective November 5, 2019

 

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). CRU is required to attend the state fair hearing to represent STAR+PLUS Home and Community Based Services (HCBS) program 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 XXXII, Create an Appeal Task in the HHSC Benefits Portal; and
  • an email to CRU at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox that includes:
    • a subject line that reads: STAR+PLUS HCBS Program Appeal Request – XX [applicant’s or member’s first and last name initials];
    • applicant or member name;
    • Medicaid identification (ID) number or Social Security number (SSN);
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service (i.e., STAR+PLUS HCBS program);
    • specific information requesting the MEPD or TW financial denial 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 MEPD or TW financial denial 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 financial denial case open pending the state fair hearing decision;
    • a copy of Form H2065-D, Notification of Managed Care Program Services; 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 4800-D, Fair Hearing Request Summary, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Refer to Section 7222.1, Continuation of STAR+PLUS HCBS 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 4800-D and the appeal identification number (ID). Once PSU staff receive the notification, PSU staff upload the notification in HEART, following the instructions in Appendix XXXIII, and monitor the appeal until the state fair hearing decision is rendered.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS 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 STAR+PLUS HCBS program interest list if the denial is sustained.

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

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.3 SSI Denial by the SSA

Revision 19-13; Effective November 5, 2019

 

If the action is related to a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA), Program Support Unit (PSU) staff are required to prepare the evidence packet and attend the state fair hearing. Refer to Section 7230, State Fair Hearing Actions, for PSU staff responsibilities for preparing the state fair hearing evidence packet.

The following are examples of documentation that must be submitted as evidence and PSU staff are responsible for uploading that information in the Texas Health and Human Services (HHSC) Benefits portal:

  • copy of Form H4803, Notice of Hearing, as a coversheet;
  • copy of the citation, Title 1 Texas Administrative Code (TAC) §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
  • copy of Section 3632.4, Denial or Termination of Financial Eligibility, as referenced in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language; and
  • copy of Form H2065-D, Notification of Managed Care Program.

PSU staff complete Form 4800-D, Fair Hearing Request Summary, entering the PSU staff and PSU supervisor as the Agency Representative and Agency Representative Supervisor.

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

  • PSU staff as the Agency Representative;
  • PSU supervisor as the Agency Representative Supervisor;
  • MCO staff as the Agency Witness; and
  • no Observer should be entered unless otherwise specified (e.g., a family member).

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the Agency Representative and Agency Representative Supervisor will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an SSI denial, on the Agency Representative field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down menu.

Continuation of STAR+PLUS HCBS program benefits during a state fair hearing does not apply for SSI denials. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information. PSU staff must not put an applicant or member back on the STAR+PLUS HCBS program interest list while an SSI denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the SSI denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.

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

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7221.4 Other Denial Reasons

Revision 19-13; Effective November 5, 2019

 

Other denial reasons include, but are not limited to:

  • unable to locate the applicant or member;
  • unable to obtain physician signature; or
  • cost of the individual service plan (ISP) exceeds the maximum amount allowed.

If the action is related to other denial reasons, the managed care organization (MCO) staff are required to prepare the evidence packet and attend the state fair hearing. PSU staff do not attend state fair hearings related to other denial reasons.

Program Support Unit (PSU) staff complete Form 4800-D, Fair Hearing Request Summary, entering the MCO staff as the Agency Representative and Agency Representative Supervisor.

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

  • MCO staff as the Agency Representative;
  • MCO supervisor as the Agency Representative Supervisor;
  • MCO staff as the Agency Witness; and
  • PSU staff and PSU supervisor as the Observer.

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to other denial reasons, on the Agency Representative field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?." PSU staff will be required to select "No" in the drop-down menu.

When Form 4800-D is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS program interest list while other denial reasons are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the other denial reason state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.

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

Refer to Section 7400, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

 

7222 Continuation or Termination of Services

Revision 19-13; Effective November 5, 2019

 

 

 

7222.1 Continuation of STAR+PLUS HCBS Program During a State Fair Hearing

Revision 19-13; Effective November 5, 2019

 

Continuation of STAR+PLUS Home and Community Based Services (HCBS) program benefits during a state fair hearing does not apply for Supplemental Security Income (SSI) denials. For all other denials, the STAR+PLUS HCBS program must continue until the hearings officer issues a decision regarding the state fair hearing of a member, if the state fair hearing request is filed within the 10-day adverse action period of the STAR+PLUS HCBS program denial or by the effective date of the action pending the state fair hearing, whichever is longer. If the state fair hearing was requested within the 10-day action adverse period or by the effective date of the action, within three business days Program Support Unit (PSU) staff must notify:

  • the managed care organization (MCO) by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, instructing the MCO to continue providing services until the hearings officer renders a decision. PSU staff must also upload a copy of Form H2067-MC in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
  • the Centralized Representation Unit (CRU) by email at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox, including:
    • a subject line that reads: STAR+PLUS HCBS Program Continued Benefits Request - XX [applicant’s or member’s first and last name initials];
    • member name;
    • Medicaid identification (ID) number;
    • HHSC Benefits portal Appeal ID number (if available);
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service (i.e., STAR+PLUS HCBS program);
    • specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial 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 regarding MN;
    • a copy of Form H2065-D, Notification of Managed Care Program Services; and
    • the witnesses’ contact information such as the managed care organization (MCO) representative and the designated MCO back-up.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four months or until the state fair hearing decision is rendered. PSU staff do not extend the medical necessity and level of care (MN/LOC) records in the Service Authorization System Online (SASO). PSU staff do not send Form H2065-D to the member or authorized representative (AR) notifying of continued eligibility related to the reassessment action taken to continue services until the state fair hearing decision is rendered.

Example: If an ISP expiration date is on December 1 and the state fair hearing decision is on December 15, then a four-month period would end on the last day of April.

If the state fair hearing is initially dismissed and subsequently re-opened, HHSC continues or reinstates services pending the state fair hearing decision, if the member or AR requests continued services. When the hearings officer sets a date for a new state fair hearing, the hearings officer, in effect, voids the prior state fair hearing decision. Because services are continued until a decision is rendered, and the hearings officer is stating there is still a state fair hearing to be held, HHSC continues or reinstates services again.

 

7222.2 Termination of STAR+PLUS HCBS Program Due to Member Not Requesting a State Fair Hearing

Revision 19-13; Effective November 5, 2019

 

If the state fair hearing request is not filed by the effective date of the action, the STAR+PLUS Home and Community Based Services (HCBS) program continues until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If a state fair hearing was not requested by the effective date of the action, Program Support Unit (PSU) staff must process according to the following:

  • For medical assistance only (MAO) members:
    • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, noting the STAR+PLUS HCBS program will be terminated effective the day after the date noted on Form H2065-D;
    • for medical necessity (MN) denials, fax Form H1746-A, MEPD Referral Cover Sheet, with Form H2065-D to Medicaid for the Elderly and People with Disabilities (MEPD) noting Medicaid coverage will need to be terminated effective the day immediately following the STAR+PLUS HCBS termination date noted on Form H2065-D;
    • send an email to the Enrollment Resolution Services (ERS) Unit mailbox requesting the member be disenrolled from STAR+PLUS following the disenrollment policy effective the day immediately following the ISP expiration date. The email to the ERS Unit mailbox must include:
      • a subject line that reads: Request for Termination - STAR+PLUS HCBS Program MN Denial - XX [member’s first and last name initials];
      • member name;
      • Medicaid identification (ID) number;
      • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
      • termination effective date;
      • a copy of Form H1746-A;
      • a copy of Form H2065-D; and
      • a copy of Form H2067-MC, Managed Care Programs Communication.
  • For Supplemental Security Income (SSI) members, Form H2067-MC must be uploaded to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, to inform the managed care organization (MCO) that the STAR+PLUS HCBS program should only continue until the effective date on Form H2065-D, which is usually the expiration date of the ISP. PSU staff must also upload a copy of Form H2067-MC in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

SSI members will remain enrolled in the STAR+PLUS MCO and are still eligible for Medicaid state plan services, which include acute care and long-term services and supports (LTSS), such as Community First Choice (CFC), Day Activity and Health Services (DAHS), Emergency Response Services (ERS) and Personal Assistance Services (PAS).

 

7230 State Fair Hearing Actions

Revision 19-13; Effective November 5, 2019

 

 

 

7231 Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal

Revision 19-13; Effective November 5, 2019

 

The data entry representative (DER) must upload all evidence packets and all supporting documentation for Supplemental Security Income (SSI) denials and medical necessity (MN) denials in the Texas Health and Human Services Commission (HHSC) Benefits portal using the process described below. Refer to Section 7213, Generation of the State Fair Hearing Packet, for examples of documentation that must be submitted as evidence.

At least 12 business days prior to the state fair hearing date, the DER must:

  • upload the supporting documentation in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
  • email the supporting documentation to Program Support Unit (PSU) staff and the PSU supervisor.

Within two business days after receipt of the evidence packet in the HHSC Benefits portal, the DER must:

  • select the Appeals/RFR tab and ensure the appeal has been entered;
  • 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); and
  • select Upload.

If an error is made on the Agency Representative screen when creating an appeal in the Texas Integrated Eligibility Redesign System (TIERS), the person who created the appeal can correct the error in Maintain Appeals.  If an error is made on any other screen when creating an appeal in TIERS, Form H4800-A, Fair Hearing Request Summary (Addendum), must be completed and uploaded in the HHSC Benefits portal. The Agency Action Date cannot be changed.

 

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 19-13; Effective November 5, 2019

 

Documentation contained in the evidence packet is not considered in the state fair hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, 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, SSI Denial by the SSA, 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 the behalf of Ned Flanders.

  • Pages 1-10 contain information relating to the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide.
  • Pages 11-15 contain policy from the STAR+PLUS Handbook (SPH) that relates directly to the issue in question.
  • Pages 16-20 contain documents signed by the applicant, member or authorized representative (AR) related to individual rights.
  • Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or AR on March 2."

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

  • Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
  • Page 2 contains a copy of the Title 1 Texas Administrative Code (TAC) §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program, that states the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) includes policies and procedures to be used by all Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR+PLUS HCBS program services to eligible applicants, members or AR.  
  • Page 3 contains a copy of the SPOPH, Section 3632.4, Denial or Termination of Financial Eligibility, as referenced in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, which states an applicant, member or AR continued receipt of STAR+PLUS HCBS program services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or medical assistance only (MAO) program requirements.
  • Page 4 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or AR on March 2nd."

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.

 

7233 State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

 

After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or authorized representative (AR) and copies all individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff and the PSU supervisor. If the decision is sustained, PSU staff take the appropriate action.

If the state fair hearing decision is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The hearings officer renders a decision and sends the written decision to the applicant, member or AR and copies all the individuals listed on Form H4800, which includes the PSU staff and PSU supervisor. PSU staff actions required by the hearings officer must be reported back in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation screen, within the 10-day time frame designated by the hearings officer.

If the applicant, member or AR requested continued services during the state fair hearing period, PSU staff follow procedures, as described in Section 7400, State Fair Hearing Decision Actions.

 

7300 Post State Fair Hearing Actions

Revision 19-13; Effective November 5, 2019

 

 

 

7310 Action Taken on the State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

 

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the PSU supervisor and data entry representative (DER). PSU staff must send Form H4807 within the 10-day time frame designated by the hearings officer to allow at least two business days for the DER to enter the information in the Texas Integrated Eligibility Redesign System (TIERS). If the action cannot be taken within the time frame designated by the hearings officer, Form H4807 is completed and sent to the PSU supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on Form H4807; the begin delay date and end delay date must be included. Refer to Form H4807 instructions for more specific directions for form completion and transmittal.

 

7400 State Fair Hearing Decision Actions

Revision 19-13; Effective November 5, 2019

 

 

 

7410 Sustained State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

 

When a hearings officer renders a sustained decision, the denial is upheld. If an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal (request for the state fair hearing), essentially sustaining the action on appeal.

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

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

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

 

7411 Sustained Decision – Termination Effective Date

Revision 19-13; Effective November 5, 2019

 

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

  • In cases where the hearings officer's decision is 30 days or more prior to the end of the individual service plan (ISP) in effect when the state fair hearing was filed, STAR+PLUS HCBS program termination is effective at the end of the ISP in effect at the time the state fair hearing was filed. Refer to Example 1 below.
  • When the hearings officer’s decision date is less than 30 days before the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date (the date the order is signed). Refer to Example 2 below.
  • When the hearings officer's decision date is after the end of the ISP in effect when the state fair hearing was filed, and a new ISP was developed to continue services past the ISP end date until the state fair hearing decision was made, the termination effective date is the end of the month that is 30 days from the hearings officer's decision date. Refer to Example 3 below.
  • If the hearings officer assigns a specific medical necessity (MN) or ISP expiration date not equal to the last day of the month, but after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that the hearings officer identified as the expiration month. Refer to Example 4 below.
  • When the hearings officer assigns a specific MN or ISP expiration date equal to the last day of the month, and this date is equal to or after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of that ISP period. Refer to Example 5 below.
  • If the hearings officer assigns a specific MN or ISP expiration date that is before the end of the MN or ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month of the original MN or ISP expiration date. Refer to Example 6 below.

Examples

Example Conditions Original MN or ISP Expiration Date New Expiration Date Hearings Officer Decision Date Final MN or Expiration Date
1 Hearings officer decision is more than 30 days from the original expiration date. 1/31/18 5/31/18 11/30/17 1/31/18
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/18 5/31/18 1/15/18 2/28/18
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/18 5/31/18 2/15/18 3/31/18
4 Hearings officer decision assigns a specific expiration date. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/15/18. 2/18/18
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/28/18. 2/18/18
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 12/31/17. 1/31/18

 

7420 Reversed State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

 

When the hearings officer’s decision reverses the denial of a STAR+PLUS Home and Community Based Services (HCBS) program for an applicant or member, within two business days Program Support Unit (PSU) staff must:

  • notify the managed care organization (MCO) by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCOs SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, that the STAR+PLUS HCBS program services are to continue as directed in the hearings officer’s decision and to request Form H1700-1, Individual Service Plan (Pg. 1), and Form H1700-2, Individual Service Plan (Pg. 2);
  • mail Form H2065-D, Notification of Managed Care Program Services, to the:
    • applicant who was denied at application to notify him or her of eligibility for the STAR+PLUS HCBS program;
    • member who was terminated at reassessment to notify him or her that the denial decision was reversed and he or she is eligible for the STAR+PLUS HCBS program for the new individual service plan (ISP) year;
    • MCO by TxMedCentral regarding the STAR+PLUS HCBS program effective date for the applicant or member;
    • Enrollment Resolution Services (ERS) Unit mailbox. The email must include:
      • a subject line that reads: Reversed Program Hearing Decision - STAR+PLUS HCBS Program - Appeal – XX [applicant’s or member’s first and last name initials];
      • applicant or member name;
      • Medicaid identification (ID) number or Social Security number (SSN);
      • Health and Human Services Commission (HHSC) Benefits portal Appeal ID number;
      • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
      • STAR+PLUS HCBS program effective date;
      • TIERS Medicaid eligibility effective date;
      • TIERS managed care effective date;
      • a copy of Form H1746-A, MEPD Referral Cover Sheet, if applicable;
      • a copy of Form H2065-D;
      • a copy of Form H2067-MC; and
      • a copy of the state fair hearing decision.
  • ensure the ISP is registered or updated in the Service Authorization System Online (SASO) with the correct effective dates; and
  • email Form H1746-A to the Centralized Representation Unit (CRU) at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox, as appropriate, to continue Medicaid eligibility. The email must include:
    • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [applicant’s or member’s first and last name initials];
    • applicant or member name;
    • Medicaid ID number or SSN;
    • HHSC Benefits portal Appeal ID number;
    • TIERS Case Number;
    • type of service (i.e., STAR+PLUS HCBS program);
    • TIERS Medicaid eligibility effective date;
    • a copy of the state fair hearing decision; and
    • upload a copy of the state fair hearing decision.

 

7421 Reversed Decision – Effective Date

Revision 19-13; Effective November 5, 2019

 

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

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

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

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

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

 

7422 New Assessment Required by State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

 

If the hearings officer’s decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Medical Necessity and Level of Care (MN/LOC) Assessment, or Form H6516, Community First Choice Assessment, the state fair hearing is closed, pending the results of the new assessment. Program Support Unit (PSU) staff must notify the applicant, member or authorized representative (AR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or AR may appeal the results of the new assessment. If the applicant, member or AR chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, on Form 4800-D, Fair Hearing Request Summary, and also during the state fair hearing, that the new assessment was ordered from a previous state fair hearing decision.

If the member or AR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a STAR+PLUS Home and Community Based Services (HCBS) program member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving prior to the MN denial. The hearings officer then orders a new MN/LOC Assessment, which results in another MN denial. PSU staff send a notice to the member or AR informing him or her of the MN denial. The member or AR then requests another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided prior to the first state fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level, and the member or AR requests a state fair hearing due to the lower RUG level, the MCO continues services at the same level services were provided prior to the first state fair hearing.

 

7423 Request to Withdraw a State Fair Hearing

Revision 19-13; Effective November 5, 2019

 

An applicant, member or authorized representative (AR) may withdraw the state fair hearing request orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing. If the applicant, member or AR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or AR to contact the hearings officer of the withdrawal by calling the hearings officer’s telephone number listed on Form H4803. If the applicant, member or AR send a written request to withdraw to PSU staff, PSU staff must forward the written request to the hearings officer listed on Form H4803.

A state fair hearing will not be dismissed based on a PSU staff decision to change the adverse action. All requests to withdraw the state fair hearing must originate from the applicant, member or AR and must be made to the hearings officer.

If the applicant, member or AR request to withdraw the state fair hearing more than five business days prior to the state fair hearing date, the hearings officer will process the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written decision to participants informing them of the state fair hearing cancellation.

If the applicant, member or AR request to withdraw the state fair hearing within five business days of the state fair hearing date, the hearings officer will notify PSU staff by telephone or email and open the conference line to inform participants of the cancellation.

 

7500 Roles and Responsibilities of HHSC Hearings Officer

Revision 19-13; Effective November 5, 2019

 

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

  • notify all hearing participants of the date and time of the state fair hearing;
  • prepare a final order disposing of a case through withdrawal and send copies of this order to the applicant, member or authorized representative (AR) and Program Support Unit (PSU) staff upon written notification from the applicant, member or AR to withdraw a state fair hearing;
  • conduct the state fair hearing;
  • consider all testimony and exhibits in making a decision;
  • reserve the right to hold a hearing record open after a state fair hearing to obtain additional information;
  • render a state fair hearing decision; and
  • send a written copy of all state fair hearing decisions to the applicant, member or AR, Texas Medicaid & Healthcare Partnership (TMHP) and PSU staff within five days of making the decision.