Revision 25-4; Effective Dec. 12, 2025

Complaint is defined as any dissatisfaction expressed by a complainant, verbally or in writing, to the Texas Health and Human Services Commission (HHSC).

A complainant enrolled in a STAR Kids managed care organization (MCO) should first contact the Member Services hotline when they want to file a complaint against their MCO.

The complainant may contact the HHSC Office of the Ombudsman’s Managed Care Assistance Team to investigate the complaint if they are not satisfied with the outcome after exhausting the MCO's complaint process. A complainant may contact the HHSC Office of the Ombudsman’s Managed Care Assistance Team by:

• phone at:
  • 866-566-8989, 8 a.m. - 5 p.m., Monday – Friday; or
  • 7-1-1 or 800-735-2989, 8 a.m. - 5 p.m., Monday – Friday, if they have a hearing or speech disability;
• submitting the Online Question or Complaint Form;
• the internet: Ombudsman Managed Care Help;
• mail at the following address: Texas Health and Human Services Commission, Ombudsman for Managed Care, P.O. Box 13247, Austin, TX 78711-3247; or
• fax at 888-780-8099.

For the Medically Dependent Children Program (MDCP), the complainant may contact the HHSC Complex Care Services (CCS) to investigate a complaint. A complainant may contact the HHSC CCS by:

• phone at 844-999-9543; or
• email at MDCP_DBMD_Escalation@hhsc.state.tx.us.

Individuals not enrolled in a MCO can call the Medicaid helpline at 800-335-8957.

7110 Privacy Complaints

Revision 26-3; Effective Aug. 14, 2026

An individual, applicant, member, or their legally authorized representative (LAR) or medical consenter can file a complaint if they believe their privacy rights were violated. File complaints with the:

• Texas Health and Human Services (HHS) Privacy Division by:
  • phone at:
    • 2-1-1 or 877-541-7905 (toll-free); or
    • 7-1-1 or 800-735-2989, (TTY), if they are hearing or speech impaired; 
  • email HHS OCC Privacy; or
  • mail to: Texas Health and Human Services, Privacy Division, PO BOX 149030, Mail Code 1355, Austin, TX 78714-9030; or 
• U.S. Department of HHS by:
  • phone at:
    • 800-368-1019 (toll-free); or
    • 800-537-1697 (TTY), if they are hearing or speech impaired;
  • online: Filing a HIPAA Complaint;
  • mail to the following address: U.S. Department of Health and Human Services, Office for Civil Rights, Region VI, 1301 Young St., Suite 106, Dallas, TX 75202; or
  • fax: 202-619-3818.

7120 PSU Staff Complaint Escalation Procedures

Revision 26-3; Effective Aug. 14, 2026 

Program Support Unit (PSU) management may receive an escalation of a complaint by email from:

• the Texas Health and Human Services Commission (HHSC) Office of the Ombudsman;
• HHSC Managed Care Contracts and Oversight (MCCO) Compliance;
• Complex Care Services (CCS);
• Program Enrollment and Support (PES) leadership;
• staff-legislative inquiries;
• HHSC Government Relations;
• HHSC Communications; or
• other reliable sources.

PSU management or their designee determines which PSU service area (SA) the escalation originated from. They forward the email to the assigned PSU staff and their supervisor within one business day of receipt. Legislative or media inquiries and escalations are subject to immediate review and response, less than a 24-hour turnaround.

The PSU supervisor or designated PSU staff must complete the following within two business days of receipt of the escalation email from PSU management:

• search the PES Escalation Intake Tracker to determine if an open escalation record exists for this person and issue;
• create a new Escalation Intake Tracker record, as needed; and
• update the Escalation Intake Tracker report with the following information:
  • Status – show the status of the escalation using a drop-down list of statuses.
    • Open – new escalation received;
    • Pending – escalation is pending completion; and
    • Closed – escalation complete, no further action needed.
  • Date Reported – record the date the escalation was received in MM/DD/YYYY format.
  • Issue Source – enter the source of the escalation.
  • Escalation Summary – provide a summary of the escalation.
  • Client/Reporter - enter the first and last name of the client the escalation is about or the person reporting the escalation, if applicable.
  • Medicaid ID or SSN – record the client’s Medicaid identification (ID) number or Social Security number (SSN). Always enter the Medicaid ID when it is available.
  • HEART Tracking Number – enter the unique tracking number assigned to the escalation record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).
  • Assigned To – specify the name of the PSU staff the escalation has been assigned to.
  • Progress Updates/Resolution – describe the steps taken to resolve the escalation. Note: Date and document any new actions or developments at least once a week.
  • Associated Files – attach relevant documents.
  • Issue Logged By – enter the person’s name or email address that is logging this escalation into the tracker.
  • ID – this field auto populates a unique identification number for each escalation entered into the tracker. No PSU action is required for this field.

The Escalation Intake Tracker record may require more updates as the escalation is being processed.

PSU staff do not log loss of Medicaid eligibility referrals in the Escalation Intake Tracker.

The assigned PSU staff must complete the following within two business days of receipt of the escalation email from PSU management:

• create a new HEART case record using the Action Type Escalation;
• review the escalation and research all issues and concerns;
• provide a response to all parties listed on the email received from PSU management indicating detailed actions taken to resolve the escalation;
• provide weekly updates to all parties if issues or concerns cannot be immediately resolved;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record once all issues are resolved.

The PSU supervisor or designated PSU staff must review the Escalation Intake Tracker and provide an update on outstanding escalations at least once a week.

Revision 25-4; Effective Dec. 12, 2025

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

A state fair hearing is an informal proceeding held before an impartial HHSC hearings officer where an applicant, member or LAR appeals an agency action, as shown in Title 1 TAC Section 357.1. 

7201 Timely or Non-timely State Fair Hearing Request

Revision 26-3; Effective Aug. 14, 2026

An applicant, member or legally authorized representative (LAR) may request a state fair hearing verbally or in writing. The managed care organization (MCO) cannot request a state fair hearing on the applicant or member’s behalf.

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

PSU staff must create the appeal in the Texas Integrated Eligibility Redesign System (TIERS) for all received state fair hearing requests. The exception is Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. PSU staff must notify Appeals and Mitigation (A&M) staff. This is done by creating an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits Portal if a fair hearing request is received for a MEPD or TW financial denial. PSU staff must refer to Appendix XXI, Creating an Appeal in TIERS and Appendix XII, Create an Appeal Task in the HHSC Benefits Portal, when creating records.

The hearing officer determines if there is good cause for a non-timely state fair hearing request. If the hearing officer determines there is no good cause the applicant or member is not eligible for a state fair hearing.

7210 Entering a State Fair Hearing In TIERS

Revision 24-4; Effective Dec. 1, 2024

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

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

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

• create a new appeal case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), if necessary; and
• enter a state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must refer to Appendix XXI, Creating an Appeal in TIERS, for detailed instructions on entering a state fair hearing in TIERS.

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

PSU staff must refer to:

• Section 7213, State Fair Hearing Evidence Packet, for additional activities PSU staff must complete on the same day as creating the fair hearing in TIERS.
• Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to an MEPD or TW financial eligibility denial.

7211 Reserved for Future Use

Revision 23-4; Effective Aug. 21, 2023

7212 Generation of the State Fair Hearing Packet

Revision 24-3; Effective Aug. 26, 2024

The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet. The packet is available to state fair hearing participants other than the applicant, member or legally authorized representative (LAR), such as Texas Health and Human Services Commission (HHSC), the Office of the Medical Director (OMD), Texas Medicaid & Healthcare Partnership (TMHP), and managed care organization (MCO) staff. A partial state fair hearing packet includes:

• Form H4800, Fair Hearing Request Summary; and
• Form H4803, Notice of Hearing.

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in TIERS that a state fair hearing is 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 it 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.  The hearings officer mails the packet to the applicant, member or LAR. A full state fair hearing packet includes:

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

7213 State Fair Hearing Evidence Packet

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must complete the following activities on the same day PSU staff enter the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS):

• prepare the state fair hearing evidence packet, as applicable;
• mail the state fair hearing evidence packet to the applicant, member or legally authorized representative (LAR);
• upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
• document the HEART case record.

PSU staff must not enter state fair hearing requests for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) Medicaid financial denials. Appeals and Mitigation (A&M) staff are responsible for creating all fair hearings related to MEPD and TW financial denials.

PSU staff must:

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

The PSU state fair hearing evidence packet includes the following:

• Form 4801, State Fair Hearing Evidence Packet Cover Page;
• Form H2065-D,  Notification of Managed Care Services;
• the appropriate handbook section, notated on Form H2065-D;
• Appendix XVII, MDCP Eligibility TAC;
• Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, as applicable, for members transitioning from MDCP due to turning 21;
• the following documents, as applicable, for medical necessity (MN) denials or terminations:
  • Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants; or
  • Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members; and
  • any written requests for a state fair hearing, first position or advanced placement.

PSU staff must ensure all state fair hearing evidence packets are complete, organized and all pages are numbered to support the agency’s action on appeal.

Other agencies that may be involved in a state fair hearing, such as the managed care organization (MCO), the Office of the Medical Director (OMD), A&M or the Texas Medicaid & Healthcare Partnership (TMHP) will:

• generate their own state fair hearing evidence packet;
• upload their state fair hearing evidence packet to the HHSC Benefits Portal; and
• mail their state fair hearing evidence packet to the applicant, member or LAR.

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

7214 Changes to the State Fair Hearing Request Summary

Revision 23-4; Effective Aug. 21, 2023

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

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

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

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

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

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

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

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

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

7221 Type of Denials

Revision 25-3; Effective Oct. 20, 2025

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

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

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

7221.1 Medical Necessity Denial by the Office of the Medical Director 

Revision 26-1; Effective March 16, 2026

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

• Create the following within two business days from receiving the appeal request:
  • A new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered.
  • A fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) following the instructions in Appendix XXI, Creating an Appeal in TIERS.
• Prepare, mail and upload the state fair hearing evidence packet, as noted in 7213, State Fair Hearing Evidence Packet. Do this on the same date PSU staff create the fair hearing in the HHS Benefits Portal.
• Complete Form H4800-A, Fair Hearing Request Summary (Addendum) if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS.
• Maintain the applicant on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant requested the fair hearing.
• Monitor the fair hearing case for the receipt of the TIERS alert showing the hearings officer rendered their decision.
• Upload all applicable documents to the HEART case record.
• Document the HEART case record.

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

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

7221.2 Financial Denial by MEPD or Texas Works

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must forward the request for a state fair hearing to Appeals and Mitigation (A&M) staff. This is if the denial involves an applicant or member not receiving Supplemental Security Income (SSI) who does not meet financial criteria through the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) programs. A&M staff must attend the state fair hearing to represent Medically Dependent Children Program (MDCP) financial denials.

Within one business day of receipt of the request, PSU staff must create:

• An appeal task in the Texas Health and Human Services (HHS) Benefits Portal in the Appeals/RFR tab for A&M staff about a financial denial for an non-SSI applicant or member. Refer to Appendix XII, Create an Appeal Task in the HHSC Benefits Portal.
• An email to A&M staff at the HHSC Access and Eligibility Services (AES) Fair Hearing mailbox that includes:
  • this subject line: MDCP Appeal Request - XX [first letter of the applicant or member’s first and last name] #### [last 4-digits of the case number];
  • the following items in the body of the email:
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service: MDCP;
    • timeliness of receipt of the appeal;
    • specific information requesting the MEPD or TW financial case remain open during the state fair hearing, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing;
    • observers contact information noted as the PSU staff and PSU supervisor;
  • a copy of Form H2065-D, Notification of Managed Care Program Services, signed, if available.
• A case record in the HHS Enterprise Administrative Report and Tracking System (HEART) documenting:
  • the receipt date of the state fair hearing request; and
  • notification to A&M staff for completion of Form H4800, Fair Hearing Request Summary.

PSU staff must refer to 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information.

A&M will send the PSU staff and supervisor listed as observers an email with the appeal ID number within five days of receipt of a state fair hearing request as notice Form H4800  was completed. PSU staff must upload the notification in the HEART case record and monitor the appeal until the state fair hearing decision is rendered.

PSU staff must:

• not put an applicant or member name back on the MDCP interest list while an MEPD or TW financial denial are in the state fair hearing process; and
• take appropriate action to certify or deny the case or resume services once the MEPD or TW financial denial state fair hearing decision is rendered.

The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

PSU staff and the PSU supervisor entered as observers are notified by an email alert from TIERS of the hearing officers rendered decision when the decision is rendered.

PSU staff must refer to 7500, State Fair Hearing Decision Actions, for more information about required actions after the decision of a state fair hearing.

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision 23-4; Effective Aug. 21, 2023

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

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

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

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

7221.4 Other Denial Reasons

Revision 25-3; Effective Oct. 20, 2025

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

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

Managed care organization (MCO) staff must prepare the evidence packet and attend the state fair hearing if the action relates to other denial reasons. PSU staff do not attend state fair hearings related to other denial reasons.

PSU staff must complete the following activities for an appeal request not related to a denial reason listed in 7221.1 through 7221.3:

• create the following within two business days from receipt of the appeal request:
  • a new appeal case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), if necessary; and
  • a state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS);
• refer to 7214, Changes to the State Fair Hearing Request Summary, as soon as possible but no later than 10 days from notification of changes to the applicant or member’s information after entering the state fair hearing in TIERS;
• monitor the state fair hearing case for the receipt of the TIERS alert showing the hearings officer rendered their decision;
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

PSU staff must refer to 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information about continuing Medically Dependent Children (MDCP) benefits during the state fair hearing.

7222 Continuation or Termination of Services

Revision 18-0; Effective September 4, 2018

7222.1 Continuation of MDCP Benefits During a State Fair Hearing

Revision 25-3; Effective Oct. 20, 2025

Medically Dependent Children Program (MDCP) benefits must continue until the hearings officer issues a decision if the member or legally authorized representative (LAR) files a state fair hearing requesting continued benefits:

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

The deadline is the date that is later.

Continuation of MDCP benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials.

PSU must refer to 6200, Adverse Action Notification Period, for more information about the adverse action notification period.

PSU staff must complete the following activities within one business day of entering a state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), if the member appeals within the adverse action notification period or by the effective date of the action:

• Extend the current STAR Kids individual service plan (SK-ISP) record and MDCP Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) in four calendar month intervals. Example: The member’s four-month period would end on April 30, 2023, if the SK-ISP expiration date is Dec. 31, 2022.
• Upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the managed care organization (MCO) to continue providing MDCP benefits until the hearings officer renders a decision.
• For members not receiving SSI, email Appeals and Mitigation (A&M) staff at the Texas HHSC Access and Eligibility Services (AES) Fair Hearings email the following:
  • this email subject line: MDCP Request for Continued Benefits – XX [first letter of the member’s first and last name] #### [last four digits of the case number];
  • the following items in the body of the email:
    • member's name;
    • Medicaid identification (ID) number;
    • HHS Benefits Portal Appeal ID number, if available;
    • TIERS case number;
    • type of service: MDCP;
    • reason for termination such as a medical necessity (MN) denial;
    • specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD), or Texas Works (TW) financial termination case remain open during the state fair hearing such as;
      • the MEPD or TW financial denial case may need to remain open pending a state fair hearing decision about MN; and
      • the witnesses’ contact information, such as the MCO representative and the designated MCO back-up.
• Upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
• Document the HEART case record.
• Monitor the case for the receipt of the TIERS alert showing the hearings officer’s decision.

Note: PSU staff must mail the member or LAR the following forms to be tested for medical assistance only (MAO) Medicaid, if the member loses Texas Works or Foster Care Medicaid during the state fair hearing:

• Form H1200, Application for Assistance – Your Texas Benefits; and
• Form 2606, Managed Care Enrollment Processing Delay.

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

HHSC continues MDCP benefits pending the hearings officer’s decision if:

• the state fair hearing is initially dismissed;
• then reopened later; and
• the member or LAR requests continued benefits.

The hearings officer voids the past fair hearing decision if they set a date for a new state fair hearing. The member must continue to receive MDCP benefits until the hearings officer renders a new state fair hearing decision.

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

Revision 24-4; Effective Dec. 1, 2024

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

A member who does not request a state fair hearing with continued benefits before the effective date of the denial will not receive continued MDCP services during the state fair hearing. PSU staff must monitor the case for the receipt of the Texas Integrated Eligibility Redesign System (TIERS) alert indicating the hearings officer’s decision.

Supplemental Security Income (SSI) members will remain enrolled in STAR Kids after MDCP termination. SSI members remain eligible for Medicaid state plan services, which include acute care and long-term services and supports (LTSS), such as Community First Choice (CFC) and Personal Care Services (PCS).

7230 State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

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

Revision 23-3; Effective May 22, 2023

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

PSU staff must:

• select the Appeals/RFR tab and ensure the appeal was entered in the Texas Integrated Eligibility Redesign System (TIERS);
• select Hearing Evidence Packets Upload and enter the appeal identification (ID) number;
• select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
• select Validate;
• check the details to ensure the right person has been selected;
• browse for the document (e.g., Form H2065-D, Notification of Managed Care Program Services);  
• select Upload;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
• document the HEART case record.

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

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

PSU staff must correct errors made on: 

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

The "Agency Action Date" cannot be changed.

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

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 22-1; Effective January 31, 2022

The hearings officer will not consider documentation in the evidence packet in the state fair hearing decision unless the packet is offered and admitted into evidence. The “Agency Representative” listed on Form H4800, Fair Hearing Request Summary, must present the packet, ask that the documents be admitted as evidence and summarize what the packet contains. Program Support Unit (PSU) staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) denial. Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration, for PSU staff state fair hearing responsibilities. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case.

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

• Pages 1-10 contain information relating to the completion of Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.
• Pages 11-15 contain policy from the STAR Kids Handbook (SKH) that relates directly to the issue in question.
• Pages 16-20 contain documents signed by the applicant, member or legally authorized representative (LAR) related to individual rights.
• Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or LAR on March 2."

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

• Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
• Page 2 contains a copy of Appendix XVII, MDCP Eligibility TAC that states the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR Kids Medically Dependent Children Program (MDCP) services to eligible applicants or members.
• Page 3 contains a copy of the Section 6300.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR Kids MDCP services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) program requirements.
• Page 4 contains Form H2065-D, which was mailed to the applicant, member or LAR on March 2nd."

The hearings officer then asks for objections and admits the documents into evidence. The hearings officer explains the reasons for excluding the material if the hearings officer is not able to admit any documents. The hearings officer considers any documents admitted when rendering a decision.

7310 Action Taken on Reversed State Fair Hearing Decisions

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff must update the hearings officer of actions taken on reversed state fair hearing decisions. This is if PSU staff attended the state fair hearing to defend the action on appeal.

PSU staff must complete the following activities for an applicant or member within 10 days from the date the hearings officer issues a reversed decision. This is if PSU staff were at the state fair hearing and defended the action on appeal:

• enter PSU staff actions taken in the Texas Integrated Eligibility Redesign System (TIERS), Hearings and Appeals, Decision Implementation screen; or
• complete Form H4807, Action Taken on Hearing Decision, and email it to the hearings officer and the PSU supervisor noting actions taken, if PSU staff cannot update the Decision Implementation screen in TIERS.

PSU staff must complete the following activities for an applicant or member  within 10 days from the date the hearings officer issues a reversed decision. This is if PSU staff were at the state fair hearing and defended the action on appeal, but face a delay in acting on the hearings officer’s decision:

• notify the PSU supervisor by email; and
• enter the reason for the delay in the Decision Implementation screen in TIERS, noting the begin and end delay dates; or
• complete Form H4807 and email it to hearings officer and the PSU supervisor, if PSU staff cannot enter the delay in the Decision Implementation screen in TIERS.
   

Revision Notice 25-4; Effective Dec. 12, 2025

Revision 25-3; Effective Oct. 20, 2025

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in the Texas Integrated Eligibility Redesign System (TIERS) advising that the hearings officer issued a decision. The hearings officer sends the written decision to all individuals entered on the state fair hearing in TIERS. This includes PSU staff and the PSU supervisor.

The hearings officer issues the following state fair hearing decisions:

• Sustained decision when the hearings officer determines the Texas Health and Human Services Commission’s (HHSC’s) action was appropriate per policy and law.
• Reversed decision when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) services.

The hearings officer specifies the corrective actions to take, and a 10-day time frame to complete these actions, if the hearing decision is reversed.

PSU staff must refer to 7310, Action Taken on Reversed State Fair Hearing Decisions, for more actions PSU staff must take if PSU staff were at the state fair hearing to defend the action on appeal, and the fair hearings officer issues a reversed decision. 

7510 Sustained State Fair Hearing Decision

Revision 26-3; Effective Aug. 14, 2026

A sustained fair hearing decision is when the hearings officer decides to uphold the Medically Dependent Children Program (MDCP) denial or termination. 

7510.1 Sustained State Fair Hearing Decision for Applicants

Revision 26-1; Effective March 16, 2026

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for applicants. 

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

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

Revision 26-1; Effective  March 16, 2026

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

• upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the managed care organization (MCO) that the:
  • hearing decision sustained the action on appeal; and
  • MCO must deliver services through the MDCP services end date in 7511, Sustained Decision – Termination Effective Date;
• complete the following steps in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP):
  • adjust the STAR Kids individual service plan (SK-ISP) and MDCP Enrollment Form to the end date noted in 7511; and
  • terminate the SK-ISP and MDCP Enrollment Form using the applicable denial reason;
• for medical assistance only (MAO) members, email: 
  • Enrollment Resolution Services (ERS) unit staff the following information:
    • this subject line: Hearings Officer Decision – STAR Kids MDCP – Sustained Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name];
    • the following items in the body of the email:
      • member's name;
      • Medicaid identification (ID) number;
      • Health and Human Services Commission (HHSC) Benefits Portal appeal ID number;
      • Texas Integrated Eligibility Redesign System (TIERS) case number;
      • MDCP termination effective date;
      • state fair hearing decision; and
    • Form H2065-D, Notification of Managed Care Program Services, as an attachment;
  • Appeals and Mitigation (A&M) staff at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to A&M staff must include the following information:
    • this subject line: Sustained Benefits for MDCP – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name];
    • the following items in the body of the email:
      • member's name;
      • Medicaid ID number;
      • type of request: notification of sustained MDCP benefits;
      • type of service: MDCP;
      • HHSC Benefits Portal appeal ID number;
      • TIERS case number;
      • MDCP termination effective date; and
      • state fair hearing decision;
• upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and 
• document and close the HEART case record.

Note: A&M staff terminate Medicaid eligibility for MAO members.

PSU staff must complete the actions in 7510.4, First Position and Advanced Placement Requests After a Sustained MN Denial. This must be done on the same day the activities above are completed, if the member’s MN denial was sustained.

PSU staff do not send Form H2065-D to notify the member or legally authorized representative (LAR) of the sustained termination.

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

Revision 26-1; Effective March 16, 2026

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for members not requesting continued Medically Dependent Children Program (MDCP) benefits. This is for any reason besides medical necessity (MN) denials by the Office of the Medical Director (OMD).

PSU staff must complete the actions in 7510.4, First Position and Advanced Placement Requests After a Sustained MN Denial, once notified of the hearings officer’s decision to sustain an MN denial.

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

7510.4, First Position and Advanced Placement Requests After a Sustained MN Denial 

Revision 26-1; Effective March 16, 2026 

Program Support Unit (PSU) staff must complete the following activities within two business days from notification of a hearings officer’s decision to sustain a Medically Dependent Children Program (MDCP) member’s medical necessity (MN) denial:

• contact the member or legally authorized representative (LAR) to discuss first position and advanced placement, if the member or LAR has not already requested first position or advanced placement: 
  • a member who previously requested first position can only be offered the advanced placement option; 
  • first position can only be pursued one time; 
  • PSU staff must attempt a second contact within two business days of this call if the member or LAR does not answer or does not have voice mail;
• document the following in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record:
  • outcome of the call using the following format: Contact [made on MM/DD/YYYY] or [attempted on MM/DD/YYYY] to phone number [XXX-XXX-XXXX] to explain state fair hearing decision, first position and advanced placement. PSU staff spoke to [first and last name of the person contacted];
  • the member’s request for:
    • first position and advanced placement, if received during the call; and
    • the following, if first position is selected:
      • a new MCO or to remain with their previous or current MCO upon interest list release (ILR); and
      • a different service coordinator with the previous or current MCO, if applicable;
• upload all applicable documents to the HEART case record; 
• document and close the HEART case record; and
• refer to 5400.2, First Position and Advanced Placement Assignments Following a Sustained MN Denial, for instructions on creating a first position and advanced placement HEART case record. 

7511 Sustained Decision – Termination Effective Date

Revision 23-4; Effective Aug. 21, 2023

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

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

The final termination effective date varies depending on the following: 

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

See below table for further clarification of each scenario.

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

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

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

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

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

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

7520 Reversed State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

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

7520.1 Reversed State Fair Hearing Decision for Applicants 

Revision 23-4; Effective Aug. 21, 2023

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

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

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

Revision 24-3; Effective Aug. 26, 2024

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

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

PSU staff must notify the Managed Care Contracts and Oversight (MCCO) Unit if the MCO fails to submit the new ISP within the required time frame.

PSU staff must include the following components when emailing the MCCO Unit staff:

• an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name];
• the following items in the body of the email:
  • member’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the MCO non-compliance and any MCO information received; and
• attachments of any pertinent documents received from the MCO, if applicable

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

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

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

Revision 23-4; Effective Aug. 21, 2023

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

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

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

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

7521 Reversed Decision – Effective Date

Revision 26-3; Effective Aug. 14, 2026

The STAR Kids individual service plan (SK-ISP) effective date for a reversed fair hearing decision depends on if the: 

• appellant is an applicant; 
• member has continued Medically Dependent Children Program (MDCP) benefits; or 
• member is without MDCP continued benefits.

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

The SK-ISP begin date for a member who received continued MDCP benefits is the first day of the month following the end of the SK-ISP in effect when the state fair hearing was filed. The managed care organization (MCO) may have to submit a new SK-ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) if the last SK-ISP expired.

The SK-ISP begin date for a member who did not receive continued MDCP benefits is the first day of the month following the hearings officer’s decision. This is unless otherwise specified by the hearings officer. The MCO may have to submit a new SK-ISP in the TMHP LTCOP if the last SK-ISP expired.

Program Support Unit (PSU) staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with Appeals and Mitigation (A&M) staff. 

PSU staff coordinate with A&M staff by sending an email to the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. This email must include:

• this subject line: MDCP Reversed Fair Hearing Decision – XX [first letter of the applicant’s or member’s first and last name] #### [last four digits of the Texas Integrated Eligibility Redesign System (TIERS) case number];
• applicant or member’s name;
• TIERS case number;
• Social Security number (SSN) or Medicaid identification (ID) number;
• Texas Health and Human Services (HHS) Benefits Portal appeal ID number, if available;
• program type: MDCP; and
• action type: Medicaid eligibility be reinstated on [date] per the reversed state fair hearing decision. 

PSU staff must refer to 7310, Action Taken on Reversed State Hearing Decisions, for:

• more actions PSU staff must take if they attended the state fair hearing to defend the action on appeal; and 
• the fair hearing officer issues a reversed decision.
   

7522 New Assessment Required by State Fair Hearing Decision

Revision 25-4; Effective Dec. 12, 2025

If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed because of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must show in the section labeled Summary of agency action and applicable handbook reference(s) or rules on Form H4800, Fair Hearing Request Summary, and also during the state fair hearing that the new assessment was ordered from a previous state fair hearing decision.

If the member or LAR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a Medically Dependent Children Program (MDCP) member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving before the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member or LAR informing him or her of the MN denial. The member or LAR then request another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided before the first state fair hearing. If the new assessment results in MN approval but a lower Patient-Driven Payment Model (PDPM) for Long-Term Care (LTC) level and the member or LAR requests a state fair hearing due to the lower PDPM LTC level, the MCO continues services at the same level services were provided before the first state fair hearing.

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018

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

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

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

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

Revision 25-1; Effective May 16, 2025

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

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

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

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

After the hearing, the hearings officer:

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