Revision Notice 25-5; Effective Dec. 17, 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 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 the STAR+PLUS Home and Community Based Services (HCBS) program.

The hearings officer specifies the corrective actions to be taken, and a 10-day time frame for the completion of the 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 went to the state fair hearing to defend the action on appeal, and the fair hearings officer issues a reversed decision. 

7410 Sustained State Fair Hearing Decision

Revision Notice 25-5; Effective Dec. 17, 2025

A sustained fair hearing decision occurs when the hearings officer renders a decision to uphold the STAR+PLUS Home and Community Based Services (HCBS) program denial or termination. For example, if an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal request for the state fair hearing, sustaining the action on appeal.

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for applicants and members who did not request continued benefits.

PSU staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued STAR+PLUS HCBS program 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 STAR+PLUS HCBS program termination effective date;
• terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7411, Sustained Decision – Termination Effective Date;
• close the Community Services Interest List (CSIL) record if the record is open;
• email the Appeals and Mitigation (A&M) unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox for medical assistance only (MAO) members;
  • the email to the A&M unit must include the following information:
    • an email subject line that states: “Sustained Denial for STAR+PLUS HCBS – 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;
    • the type of request for example notification of sustained denial of the STAR+PLUS HCBS program;
    • the type of service such as STAR+PLUS HCBS program;
    • HHSC Benefits Portal appeal ID number;
    • the Texas Integrated Eligibility Redesign System (TIERS) case number;
    • STAR+PLUS HCBS program termination effective date; and
    • the 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.

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

7411 Sustained Decision – Termination Effective Date

Revision 19-13; Effective November 5, 2019

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

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

Examples

7420 Reversed State Fair Hearing Decision

Revision 26-1; Effective Feb. 20, 2025

Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the hearings officer’s decision to reverse the denial or termination of STAR+PLUS Home and Community Based Services (HCBS) program within two business days. They do this by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub. PSU staff must notate the following on Form H2067-MC:

• STAR+PLUS HCBS program services should continue as directed in the hearings officer’s decision, as applicable; and
• the MCO must upload a new ISP to the MCOHub or to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), as applicable.

PSU staff must complete the following activities for applicants within two business days of receipt of the ISP:

• Manually generate Form H2065-D, Notification of Managed Care Program Services. For all applicants, the ISP begin date is the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer.
• Mail Form H2065-D to the applicant.

Upload Form H2065-D to the MCOHub.

• Ensure the ISP is updated in the Service Authorization System Online (SASO) with the correct effective dates.
• For medical assistance only (MAO) applicants, notify Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
  • a subject line that reads: Reversed Hearing Decision – STAR+PLUS HCBS Appeal for XX [first letter of the applicant’s first and last name]. For example, the email subject line for a STAR+PLUS HCBS program termination reversal for Ann Smith would be “Reversed Hearing Decision – STAR+PLUS HCBS Appeal for AS”;
  • the applicant’s name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • Health and Human Services Commission (HHSC) Benefits portal Appeal ID number;
  • Texas Integrated Eligibility Redesign System (TIERS) case number;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • Form H2065-D; and
  • the state fair hearing decision;
• For MAO applicants, notify Appeals and Mitigation (A&M) staff by email at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to A&M staff must include:
  • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the applicant’s first and last name];
  • the applicant’s name;
  • Medicaid ID number or SSN;
  • type of request such as continue or reinstate Medicaid eligibility;
  • type of service such as  STAR+PLUS HCBS program;
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • TIERS Medicaid eligibility effective date;
  • Form H1746-A , MEPD Referral Cover Sheet;
  • Form H2065-D; and
  • the state fair hearing decision.
• Upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.
• Document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of receipt of the ISP:

• electronically generate Form H2065-D in the TMHP LTCOP;
  • for a member who did not receive continued benefits, the ISP begin date is the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
  • for a member who did receive continued benefits, the ISP begin date is the first day of the month following the termination date;
• mail Form H2065-D to the member;
• ensure the ISP is updated in SASO with the correct effective dates;
• for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
  • a subject line that reads: Reversed Program Hearing Decision - STAR+PLUS HCBS Program - Appeal – XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • ISP receipt date;
  • ISP begin date;
  • ISP end date;
  • TIERS Medicaid eligibility effective date;
  • TIERS managed care effective date;
  • Form H2065-D; and
  • the state fair hearing decision;
• for MAO members, notify A&M staff by email at the HHSC AES Fair Hearings mailbox. The email to A&M staff must include:
  • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the member’s first and last name];
  • the member’s name;
  • Medicaid ID number;
  • type of request (i.e., continue or reinstate Medicaid eligibility);
  • type of service (i.e., STAR+PLUS HCBS program);
  • HHSC Benefits portal Appeal ID number;
  • TIERS case number;
  • TIERS Medicaid eligibility effective date;
  • Form H1746-A;
  • Form H2065-D; and
  • the state fair hearing decision;  
• upload all applicable documents to the HEART case record; and
• document and close the HEART case record.

7421 Reversed Decision – Effective Date

Revision Notice 26-2; Effective June 1, 2026

The STAR+PLUS Home and Community Based Services (HCBS) program individual service plan (ISP) effective date for a reversed fair hearing decision depends on if the:

• appellant is an applicant;
• member has continued STAR+PLUS HCBS program benefits; or
• member is without STAR+PLUS HCBS program continued benefits.

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

The ISP begin date for a member who received continued STAR+PLUS HCBS program benefits is the first day of the month after the end of the ISP in effect when the state fair hearing was filed.

The ISP begin date for a member who did not receive continued STAR+PLUS HCBS program benefits is the first day of the month after the hearings officer’s decision, unless otherwise specified by the hearings officer.

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

PSU staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with the 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:

• a subject line that reads: STAR+PLUS HCBS Program 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;
• Medicaid identification (ID) number or Social Security number (SSN);
• Health and Human Services (HHS) Benefits Portal appeal ID number, if available;
• TIERS case number;
• program type: STAR+PLUS HCBS program; and
• action type: Medicaid eligibility be reinstated on [date] as instructed in the reversed state fair hearing decision. 

PSU staff must refer to 7310, Action Taken on the State Fair Hearing Decision, 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.

7422 New Assessment Required by State Fair Hearing Decision

Revision Notice 25-5; Effective Dec. 17, 2025

The state fair hearing is closed, pending the results of the new assessment if the hearings officer’s decision orders completion of a new:

• Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Medical Necessity and Level of Care (MN/LOC) Assessment; or
• Form H6516, Community First Choice Assessment.

Program Support Unit (PSU) staff must notify the applicant, member or authorized representative (AR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or AR may appeal the results of the new assessment. If the applicant, member or AR chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, on Form 4800-D, Fair Hearing Request Summary, and also during the state fair hearing, that the new assessment was ordered from a previous state fair hearing decision.

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

7423 Request to Withdraw a State Fair Hearing

Revision 19-13; Effective November 5, 2019

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

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

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

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