Revision 17-1; Effective June 1, 2017

 

 

7100 Managed Care Organization Procedures

Revision 17-1; Effective June 1, 2017

 

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) §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 17-1; Effective June 1, 2017

 

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. §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 regarding an agency licensed by HHSC, or any other state agency, the member is referred to 1-800-458-9858 to file a regulatory complaint. If the complaint is initially received by HHSC, HHSC will inform the MCO of the complaint.

Members may also call the HHSC Ombudsman's Managed Care Assistance Team at 1-866-566-8989 for assistance filing a complaint not related to licensure issues.

 

7120 Managed Care Organization Internal Appeal Procedures

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) STAR Kids Contract, Attachment A, defines an appeal as the formal process by which 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) §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 following 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 §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 17-1; Effective June 1, 2017

 

In accordance with 42 Code of Federal Regulations §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 three business days. However, the MCO must complete investigation and resolution of an internal appeal relating to an ongoing emergency or denial of continued hospitalization:

  • in accordance with 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 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 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, prior to HHSC’s fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his/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.

 

7200 State Fair Hearing Procedures for Medically Dependent Children Program

Revision 17-1; Effective June 1, 2017

 

 

7210 Program Support Unit Procedures

Revision 17-1; Effective June 1, 2017

 

When a request for a state fair hearing related to 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. The PSU staff either:

  • send the form to the regional data entry representative (DER) within three calendar days of the request for a hearing, which allows the DER two days to enter the information into the Texas Integrated Eligibility Redesign System (TIERS); or
  • enter the request for a fair hearing into TIERS, ensuring it is entered within five calendar days from the date of the request.

Form H4800 records the names, titles, addresses and telephone 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. PSU staff should contact the MCO if there is doubt as to who should be listed on Form H4800.

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).

When PSU staff complete Form H4800, all questions in Section 3, Appellant Details Programs, must be answered. In Subsection D, Summary of Agency Action and Citation, staff must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

PSU staff must indicate the ISP begin and end dates, as applicable, in Section 3.D., Summary of Agency Action and Citation. The begin and end dates must also be mentioned during the state fair hearing so the hearings officer is aware of when the ISP year ends when rendering a hearing decision regarding the MDCP waiver denial.

The format for Form H4800 follows the data entry screens. See the form instructions for more specific directions for completion and transmittal.

 

7211 Designated Data Entry Representative Procedures

Revision 17-1; Effective June 1, 2017

 

Within two calendar days of receipt of Form H4800, Fair Hearing Request Summary, the data entry representative (DER) enters the information into the Hearings and Appeals section of the Texas Integrated Eligibility Redesign System (TIERS). When entry of all information is complete, the system assigns the appeal identification (ID) number. The DER notes the appeal ID number on the bottom of the form and in the designated space on the front of the form, and sends a copy back to the Program Support Unit staff.

 

7212 Fair Hearings and Appeals Procedures

Revision 17-1; Effective June 1, 2017

 

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet, which includes:

The Program Support Unit (PSU) staff and supervisors receive a copy of Form H4800 and Form H4803, identifying the hearings officer assigned to the appeal and the date, time and location of the hearing. PSU staff are not expected or required to attend state fair hearings.

 

7213 Evidence Packet

Revision 17-1; Effective June 1, 2017

 

All related documentation necessary to support the determination on an appeal must be uploaded into the State Portal and mailed to the appellant at least 10 business days prior to the hearing. Each entity involved in the action taken is responsible for preparing its evidence packet, uploading it to the State Portal, and forwarding it to the appellant. 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 State Portal:

  • Managed care organization (MCO):
    • MCO policy handbook, STAR Kids Handbook and/or STAR Kids contract/STAR Kids Managed Care Manual;
    • summary of events;
    • other documentation supportive of the determination, such as documentation of telephone 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 telephone 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: a copy of the original signed Form H2065-D, Notification of Managed Care Program Services (if available, use the signed copy of the form returned by the applicant/member when the state appeal was filed).

 

7214 Fair Hearing Request Summary (Addendum)

Revision 17-1; Effective June 1, 2017

 

After the data entry representative (DER) or Program Support Unit (PSU) staff has added information from Form H4800, Fair Hearing Request Summary, into the Texas Integrated Eligibility Redesign System (TIERS), PSU may learn of subsequent changes such as address changes, withdrawal forms or additional supporting documents needed for a state fair hearing. When this occurs, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the designated DER who will check TIERS to identify if a hearings officer has been assigned to the case. In the event the updates need to be communicated to the hearings officer, PSU staff complete and forward Form H4800 to the DER.

If a hearings officer is not yet assigned, the DER must wait until one is assigned to send the additional information. When sending information, the DER completes the following activities according to the situation:

  • When PSU staff submit Form H4800-A or Form H4800 to the DER, the DER sends the form(s) directly to the hearings officer’s email address with the appeal ID number in the subject line.
  • If the PSU staff submission to the DER includes additional supporting documentation for a state appeal, the DER not only emails Form H4800-A to the assigned hearings officer, but also uploads the supporting documentation directly into the State Portal. The email sent by the DER must include the appeal ID number in the subject line, as referenced above, and inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded to the State Portal.

PSU staff and the DER must follow current time frames and procedures to ensure supporting documentation is uploaded into the State Portal no later than 10 calendar days prior to the state fair hearing date.

 

7220 Special Procedures for Cases – Medicaid for the Elderly and People with Disabilities or Texas Works Determined Financial Eligibility

Revision 17-1; Effective June 1, 2017

 

 

7221 Centralized Representation Unit

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) Medical and Social Services (MSS) maintain a Centralized Representation Unit (CRU) to handle all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works (TW) staff. CRU replaces the MEPD staff in specific steps related to the denial of MEPD applications and ongoing cases. The CRU:

  • represents HHSC MSS in state fair hearings, which includes both TW and MEPD;
  • completes and implements all TW/MEPD case actions based on fair hearing decisions for all appeals initiated by the CRU; and
  • coordinates actions required with TW/MEPD and Program Support Unit (PSU) staff.

PSU staff must coordinate all state appeals involving TW/MEPD-related eligibility with CRU, including Medically Dependent Children Program (MDCP) waiver cases. The procedures in Section 7222 below must be used to coordinate state appeal actions with CRU in cases for which TW or MEPD staff determine financial eligibility. All correspondence on state appeals will go to the CRU supervisor and the CRU administrative assistant.

 

7222 Program Support Unit Procedures

Revision 17-1; Effective June 1, 2017

 

Program Support Unit (PSU) staff are responsible for completing Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/member requests a state fair hearing. For state appeals that involve the Centralized Representation Unit (CRU), the method in which the form is completed depends on the action being appealed. PSU staff must determine if the appealed action is a:

  • Medically Dependent Children Program (MDCP) waiver denial (excludes denials based on a Texas Works/Medicaid for the Elderly and People with Disabilities (TW/MEPD) denial action; or
  • TW/MEPD financial denial (denials based on a TW/MEPD denial action).

If the appealed action is related to an MEPD waiver denial based on an eligibility factor other than financial, PSU staff complete Form H4800, entering the managed care organization (MCO) contact as the agency representative.

If the appealed action is related to an MDCP waiver denial based on a TW/MEPD financial denial, PSU staff complete Form H4800 and enter the name of the PSU staff person who will appear at the fair hearing as the agency representative. This information must be entered through the Manage Office Resources (MOR) search function for the PSU staff person to receive the hearing information.

For members requesting continued benefits and who are part of the Medical Assistance Only eligibility group, when Form H4800 is sent to the designated data entry representative, PSU staff send an email notification regarding the request for a state fair hearing to CRU. PSU staff send the email to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings. In the subject line of the email, include the following: Request for Continued Benefits- Appeal ID-XXXXXXX. In an attachment to the email, staff must also include a copy of the notification form sent to the applicant or member.

The email must include:

  • applicant's/member's name;
  • Medicaid number (if available);
  • type of service (MDCP waiver); and
  • specific information requesting TW/MEPD financial case remain active/open during the state fair hearing, if the member appealed in a timely manner and requested continued benefits. For example, the financial case may need to remain open pending an appeal decision regarding medical or functional eligibility.

When an MDCP waiver denial fair hearing decision is rendered by the hearings officer, the PSU staff are notified via email of the decision by the hearings officer. Based on the hearing decision, PSU staff determine the appropriate action for the waiver according to program-specific time frames. For more information, refer to Section 7500, Hearing Decision Actions.

PSU staff may need to coordinate effective dates of reinstatement with CRU and must send an email to the HHSC OES Fair Hearings mailbox, and include Form H1746-A, MEPD Referral Cover Sheet. PSU staff report the implementation of the hearing decision through TIERS Decision Implementation.

If a member appeals a Medicaid denial issued by the TW or MEPD program, the CRU enters the fair hearing request in TIERS and notifies PSU the applicant/member appealed the Medicaid denial by sending an email to the PSU supervisor and backup designee. When notifying the PSU, CRU staff use the following subject line: "URGENT: STAR Kids member appealed financial denial of MDCP program. MCO Plan Code XX (if available)." The CRU processes the fair hearing request of the Medicaid denial following established procedures. CRU does not list the MCO or PSU staff on the fair hearing request.

Within two business days of receiving the notice the applicant or member is appealing the financial denial, the PSU contacts the applicant or member, or his or her authorized representative, to determine whether he or she wants to appeal the MDCP program denial. If so, PSU staff process the fair hearing request following established procedures.

For TW/MEPD appeals, once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU must notify PSU staff by sending an email to the PSU supervisor and backup designee of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, PSU staff determine the appropriate action for the MDCP waiver. The email sent by CRU includes the:

  • applicant's/member's name;
  • TIERS case number; and
  • copy of the hearing decision.

If Medicaid eligibility will be denied, the CRU includes the effective date of the Medicaid denial in the email. If Medicaid eligibility will be reinstated, the PSU must send the CRU an email with Form H1746-A to the HHSC OES Fair Hearings mailbox, indicating all other eligibility criteria are in place and Medicaid needs to be reestablished. The CRU will respond to the PSU by sending an email to the PSU supervisor and backup designee with the effective date of Medicaid eligibility.

PSU staff must not put an applicant/member back on the MDCP waiver interest list while a TW/MEPD denial is in the state appeal process. PSU staff must take appropriate action to certify or deny the case, or resume services once the TW/MEPD hearing decision is rendered. The individual may choose to be added back to the MDCP waiver interest list once staff deny the waiver.

 

7230 Evidence Packet and Hearing Decision

Revision 17-1; Effective June 1, 2017

 

 

7231 Uploading the Appeals Evidence Packet into the State Portal

Revision 17-1; Effective June 1, 2017

 

All evidence packets must be uploaded into the State Portal using the process described below. The regional data entry representative (DER) uses Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation (also referred to as the appeals packet) to the hearings officer. The appeal identification number assigned by Texas Integrated Eligibility Redesign System (TIERS) must be written on the top of Form H4800-A.

At least 12 business days prior to the fair hearing date, the Program Support Unit staff must:

  • scan the documentation;
  • save the document by either allowing the default document name or entering a name of the user's choosing;
  • retrieve the scanned document and attach it to an email; and
  • send the document to the regional DER.

Within two business days after receipt, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the State Portal and select the Appeals tab, without launching TIERS;
  • ensure the appeal has been entered in TIERS (this requirement must be met before the next step can be completed);
  • select Hearing Evidence Packets Upload and enter the Appeal ID;
  • 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; and
  • select Upload.

Users who make mistakes they are unable to reverse may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

 

7232 Presentation of the Evidence Packet

Revision 17-1; Effective June 1, 2017

 

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 Program Support Unit (PSU) staff and supervisors receive a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time and location of the hearing. PSU staff are not expected or required to attend state fair hearings.

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 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.

 

7233 Hearing Decision

Revision 17-1; Effective June 1, 2017

 

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, which includes Program Support Unit (PSU) staff. If the determination on appeal is sustained, the PSU staff take the appropriate action. If the member requested continued services during the state appeal period, the PSU follows procedures described in Section 7500, Hearing Decision Actions.

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. PSU staff actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation, within the 10-day time frame designated by the hearings officer.

 

7300 Post Hearing Actions

Revision 17-1; Effective June 1, 2017

 

 

7310 Action Taken on the Hearing Decision

Revision 17-1; Effective June 1, 2017

 

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the designated data entry representative (DER). PSU staff must send Form H4807 within the time frame specified by the hearings officer to allow at least two days for the DER to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, Form H4807 is completed and sent to the supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on the form; the begin delay date and end delay date must be included.

 

7400 Continuation of Services

Revision 17-1; Effective June 1, 2017

 

 

7410 Continuation of Medically Dependent Children Program Waiver Services During a State Appeal

Revision 17-1; Effective June 1, 2017

 

Medically Dependent Children Program (MDCP) waiver services must continue until the hearings officer issues a decision regarding the appeal of an active MDCP waiver member, if the appeal is filed by the effective date of the action pending the appeal. If a state appeal was requested by the effective date of the action, Program Support Unit (PSU) staff must promptly notify the managed care organization (MCO) by posting Form H2067-MC, Managed Care Programs Communication, to the MCO via TxMedCentral and uploading a copy of this form in the HHS Enterprise Administrative Record Tracking (HEART) system.

If the member requests 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 TxMedCentral.

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 calendar months or until the outcome of the state appeal is determined. PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to the member notifying of continued eligibility related to the reassessment action taken to continue services until the appeal decision is issued.

If a state appeal is initially dismissed and subsequently re-opened, the Texas Health and Human Services Commission (HHSC) continues/restarts services pending the appeal outcome, if the member requests continued services. When the hearings officer sets a date for a new hearing, he in effect, voids the prior hearing decision. Because services are continued until a decision is rendered, and the hearings officer is stating there is still a hearing to be held, HHSC continues/re-starts services again.

 

7420 Discontinuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 17-1; Effective June 1, 2017

 

If a state fair hearing is not requested by the effective date of the action, 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). The Program Support Unit (PSU) must complete Form H2067-MC, Managed Care Programs Communication, and process according to the following:

  • For Medical Assistance Only (MAO) members, Form H2067-MC is:
    • posted to TxMedCentral to inform the managed care organization (MCO) MDCP waiver services must continue until the end of the ISP period or the Medicaid denial date, as notated on Form H2065-D; and
    • emailed to Enrollment Resolution Services to disenroll from STAR Kids following the disenrollment policy effective the day immediately following the ISP expiration date for MAO MDCP members only.
  • For Supplemental Security Income (SSI) members, Form H2067-MC should be posted to TxMedCentral to inform the MCO that MDCP waiver services should only continue until the effective date of the action, which is usually the expiration date of the ISP.

SSI 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.

 

7500 Hearing Decision Actions

Revision 17-1; Effective June 1, 2017

 

 

7510 Sustained Appeal Decisions

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision sustains the denial of Medically Dependent Children Program (MDCP) waiver services, Program Support Unit (PSU) staff must:

  • notify the member via telephone or letter (if the individual does not have a telephone) of the hearings officer's decision and the termination effective date;
  • notify the managed care organization by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, to deliver services through the MDCP waiver termination effective date if services were continued during the state fair hearing process;
  • terminate MDCP services by end-dating the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) portal effective the MDCP termination effective date;
  • send an email to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings, notifying the Centralized Representation Unit (CRU) of the hearings officer's decision and the termination effective date for non-Supplemental Security Income(SSI) recipients; and
  • notify Enrollment Resolution Services (ERS) of the hearings officer's decision and the termination effective date for non-SSI recipients. ERS disenrolls non-SSI recipients from STAR Kids.

PSU must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the member of the sustained denial.

 

7511 Sustained Decisions – Termination Effective Dates

Revision 17-1; Effective June 1, 2017

 

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 will vary depending on the following circumstances.

  • In cases where the hearings officer's decision is 30 calendar days or more prior to 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. 1/31/16 5/31/16 11/30/15 1/31/16
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/16 5/31/16 1/15/16 2/28/16
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/16 5/31/16 2/15/16 3/31/16
4 Hearings officer decision assigns a specific expiration date. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 2/15/16. 2/29/16
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 2/29/16. 2/29/16
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 12/31/15. 1/31/16

 

7520 Reversed Appeal Decisions

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision reverses the denial of a Medically Dependent Children Program (MDCP) waiver applicant or member, Program Support Unit (PSU) staff must:

  • notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, that MDCP waiver services are to continue as directed in the hearings officer's decision and to request Form 2603, STAR Kids Individual Service Plan (ISP) Narrative;
  • send Form H2065-D, Notification of Managed Care Program Services, within two business days to the:
    • member who was terminated at reassessment to notify him the denial determination was reversed and he is eligible for MDCP waiver services for the new individual service plan (ISP) year;
    • applicant who was denied at application to notify him of eligibility for MDCP waiver services;
    • MCO regarding applicants and members at reassessment of the MDCP waiver effective date; and
    • Enrollment Resolution Services staff regarding applicants and the MDCP waiver effective date and enrollment date; and
  • ensure the ISP is registered or updated in the Long Term Care online portal with the correct effective dates; and
  • send an email with Form H1746-A, MEPD Referral Cover Sheet, to the Texas Health and Human Services (HHSC) Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings, notifying the Centralized Representation Unit (CRU) of the hearings officer's decision and the member meets all eligibility criteria for the MDCP waiver, for non-Supplemental Security Income recipients. The CRU will respond to the PSU by sending an email to the PSU supervisor and backup designee with the effective date of Medicaid eligibility.

 

7521 Reversed Decisions – Effective Dates

Revision 17-1; Effective June 1, 2017

 

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

  • reassessment is one day after the end of the individual service plan in effect when the state fair hearing was filed; and
  • MDCP waiver denied at 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.

 

7522 New Assessment Required by Fair Hearing Decision

Revision 17-1; Effective June 1, 2017

 

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 prior to the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member informing him 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 prior to 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 would continue services at the same level services were continued prior to the first fair hearing.

 

7523 Request to Withdraw an Appeal

Revision 17-1; Effective June 1, 2017

 

An appellant or appellant representative must request to withdraw his appeal by sending written notice to the hearings office. The hearings office cannot accept an oral request to withdraw his or her appeal. If the appellant or appellant representative contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the appellant or the appellant's representative the request to withdraw the appeal must be a written notice to the hearings office. If the appellant or appellant's representative sends a written request to withdraw to PSU staff, PSU staff must forward this written request to the hearings office. All requests to withdraw the hearing must originate from the appellant or appellant representative and must be made to the hearings office.

If the appellant or appellant's representative requests to withdraw his appeal within 14 calendar 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 appellant or appellant's representative requests to withdraw his state appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System and will send a written notice to participants informing them of the fair hearing cancellation.

 

7600 Roles and Responsibilities of Texas Health and Human Services Commission Hearing Officers

Revision 17-1; Effective June 1, 2017

 

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

  • notifies all persons 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 and sends copies of this order to the appellant and Program Support Unit (PSU) upon written notification from the appellant to withdraw a state appeal;
  • conducts the hearing;
  • uses the Texas Medicaid & Healthcare Partnership (TMHP) nurse to determine whether any new medical information introduced at the hearing meets the medical necessity (MN) criteria for nursing facility care;
  • reserves the right to hold a case open after a hearing pending medical review by TMHP physicians;
  • 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/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). Program staff may disagree with the decision; however, the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by program staff to the regional attorney.

 

7700 Fair Hearings for Managed Care Organization Determinations

Revision 17-1; Effective June 1, 2017

 

If an applicant wishes to request a fair hearing with the state of Texas regarding a Medically Dependent Children Program (MDCP) waiver eligibility denial, he or she 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.