Texas Department of Aging and Disability Services
Case Manager Medically Dependent Children Program Handbook
Revision: 14-1
Effective: February 3, 2014

Section 9000

Service Reductions, Suspensions, Denials, Case Closures, Appeals and Fair Hearings

9100  Notification Forms for Service Reductions, Suspensions, Denials and Case Closures

Revision 13-4; Effective November 1, 2013

The case manager completes Form 2065-B, Notification of Waiver Services, to:

  • notify the individual of a service reduction, as applicable; and
  • deny the applicant's/individual's request for a service that does not:
    • meet the service criteria; or
    • impact the applicant's/individual's program eligibility.

The case manager completes Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to:

  • notify the applicant/individual of denied program eligibility;
  • suspend the individual's waiver services; and
  • notify providers of DADS decision.

The date at the top of Form 2065-B and Form 2065-C is the date the case manager completes the form. The date at the top of the form does not take into consideration the mail date of the form. The case manger must still ensure applicants and individuals are notified within required time frames. For situations requiring adverse action, the case manager must complete the notification in a timely manner to ensure the individual is given the full adverse action time period.

As applicable, the case manager must update or complete service authorization forms for active waiver services authorized in the Individual Plan of Care (IPC) after determining a service reduction, suspension, denial or case closure is needed. The service authorization forms are:

  • Form 2402, Consumer Directed Services Option – Respite/Flexible Family Support Services Authorization;
  • Form 2414, Flexible Family Support Services Authorization;
  • Form 2415, Respite Service Authorization;
  • Form 2416, Minor Home Modifications and Adaptive Aids Services Authorization; and
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

Policy in the following sections directs the case manager to the appropriate form(s) to use for specific case actions.

9110  Exceptions to the 30-day Notification Time Frame

Revision 12-1; Effective May 1, 2012

§51.243

(d)
Notifications.
(1)
The effective date of the service reduction, service denial, or case closure is 30 days after the date on the individual's notification letter.
(2)
DADS notifies the individual in writing of the process to appeal the service reduction, service denial, or case closure as described in §51.251 of this chapter (relating to Appeals).

In most situations, the case manager must provide 30 days notification to the individual for any case action that is a service reduction, service denial or case closure. The intent of the 30-day notification time frame is to allow the individual and primary caregiver sufficient time to adjust to DADS decision.

In some instances, delaying denial or reduction of services for 30 days may have an adverse effect on the individual. In these instances, DADS may provide less than 30 days notification for service reductions, service denials or case closures. These instances may include:

  • a service reduction in order to add or increase a waiver service to the individual plan of care (IPC); or
  • a case closure for an individual voluntary withdrawal/enrolling into another waiver program. This exception does not apply to an individual aging out since the MDCP termination date is known.

If the individual/primary caregiver requests the case action occur before the 30-day notification time frame, the case manager must inform the individual/primary caregiver that he:

  • has a right to a 30-day notification period before the case action may occur; and
  • may waive the 30-day notification period by completing Form 1574, Exception to the 30-Day Notification.

Within two working days of receiving a request to waive the 30-day notification for a service reduction, service denial or case closure, the case manager must send the individual, or the individual's parent or guardian, Form 1574. Form 1574 must be completed and returned to the case manager before the date of the required 30-day notification of a service reduction, service denial or case closure.

If Form 1574 is not returned to the case manager before the date of the required 30-day notification of a service reduction, service denial or case closure, the case manager must send the notification for the service reduction, service denial or case closure 30 days in advance of the effective date.

When an individual, or the individual's parent or guardian, requests a service reduction or case closure with an effective date that is less than 30 days from the request date, Form 1574 must be returned before the effective date of the requested service reduction or case closure.

The case manager must complete the change to the IPC within two working days of receipt of a completed Form 1574. The two-working-day time frame for the change to the IPC is specific for case actions in which the individual/primary caregiver requested to waive the 30-day notification period. The case manager must also negotiate the effective date for the case action with the individual/primary caregiver and the provider. It is important to include the provider in the negotiation of the effective date to prevent unauthorized service delivery after the IPC effective date.

Service Reduction Notification

The case manager must complete Form 2065-B, Notification of Waiver Services, when adding and reducing services in this case action. The case manager must complete and send Form 2065-B and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of completing the IPC.

Case Closure Notification

In a case closure due to voluntary withdrawal from the program, the termination date is the last date the individual/primary caregiver requests MDCP services. The case manager may negotiate the date if the individual/primary caregiver did not identify a specific date.

In situations in which the individual/primary caregiver does not know the last day in which MDCP services are needed, the case manager may not be able to negotiate the effective date of the case action. In these cases, the MDCP case closure date is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver. The case manager must contact the provider at least two working days before the case closure effective date to prevent the provider from delivering services to the individual after the case closure date. The contact may be by telephone or on Form 2067, Case Information.

The case manager must complete Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, for case closures. The effective date of Form 2065-C, and applicable service authorization forms identified in Section 9100, is the last day of MDCP eligibility, which may be the day before enrollment in the other waiver program or the last day of MDCP services requested by the individual/primary caregiver. The case manager must complete and send Form 2065-C and applicable service authorization forms to the individual and the provider within two working days of determining program ineligibility.

If the case manager is unsure when an individual's written request is needed, he may consult with the MDCP supervisor.

The case manager must document all telephone contacts, dates of contact and outcome with the individual/primary caregiver and provider in the case file using Form 2405, Narrative Notes.

9200  Service Reductions

Revision 13-2; Effective May 1, 2013

§51.243

(b)
Service reductions. DADS will reduce services to an individual when:
(1)
third-party resources become available to the individual;
(2)
the individual's annual cost ceiling decreases; or
(3)
budgetary constraints require cost reductions.
(d)
Notifications.
(1)
The effective date of the service reduction, service denial, or case closure is 30 days after the date on the individual's notification letter.
(2)
DADS notifies the individual in writing of the process to appeal the service reduction, service denial, or case closure as described in §51.251 of this chapter (relating to Appeals).

A reduction in services means a decrease in the amount of previously authorized MDCP services. Not all changes to the individual's individual plan of care (IPC) are considered a reduction in services. Example: An individual may have a change from receiving Respite delivered by a registered nurse (RN) to Respite delivered by a licensed vocation nurse (LVN). The cost of waiver services decreased but there was no change to the hours authorized to the individual. In this case, the individual did not have a service reduction.

The case manager must assess third-party resources (TPRs) to determine if MDCP services must be reduced. It is possible an individual may have a TPR identified during the IPC development or one may become available during the IPC period. If the TPR changes the individual's/caregiver's need for waiver services, the case manager must reduce services in the IPC. Note: The availability of a TPR does not necessarily impact the individual's/caregiver's need and use for MDCP services.

Other situations may cause a reduction in services, such as an individual's request to decrease services.

Provider Information for Completing Service Reductions

When the case manager plans a change to the IPC for a service reduction, it may be necessary to obtain service delivery information from providers to complete the change. When this occurs, the case manager must verify the number of units or the cost of services delivered by the provider from the authorized start date through the day before the IPC change is effective. The case manager will use that information to plan the impact of the service reduction for the remainder of the IPC period.

The case manager must use Form 2067, Case Information, to request the total:

  • number of units for Respite and/or Flexible Family Support Services delivered by the Home and Community Support Services Agency (HCSSA) delivered from the authorized start date through the day before the IPC change effective date;
  • cost of services from the Consumer Directed Services Agency (CDSA), for Respite and/or Flexible Family Support Services; or
  • cost of adaptive aids, minor home modifications or Transition Assistance Services (TAS) delivered to the individual up to the IPC change effective date.

The case manager must complete and send Form 2065-B, Notification of Waiver Services, and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of completing the service reduction to the IPC. The effective date of Form 2065-B and applicable service authorization forms for a service reduction is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period. See Section 9110, Exceptions to the 30-Day Notification Time Frame.

The case manager must follow procedures in Section 5110, Interim Plan of Care, or Section 5120, Budget Revision, as applicable to complete the reduction in services as a change to the IPC. The effective date of an IPC change resulting from a service reduction is 30 days from the date on Form 2065-B.

The case manager must follow procedures in Section 4230, Service Authorization System (SAS), for SAS data entry procedures for service reduction case actions. Consult the SAS help file for SAS record data entry procedures for service reduction actions.

9300  Denying Requests for Specific Services

Revision 12-1; Effective May 1, 2012

When an individual or caregiver requests a waiver service, the case manager must determine if the need for the service falls within the service criteria. See Section 4100, Medically Dependent Children Program (MDCP) Services, for a review of waiver service criteria. If the request for a specific waiver service does not meet the service criteria, the case manager denies the request using Form 2065-B, Notification of Waiver Services, and uses information found in Attachment A, MDCP Comments for Denying Requests for Specific Services, of the form instructions to complete the Comments part of the form.

The case manager must complete and send Form 2065-B to the individual within two working days of determining the request for the waiver service did not meet waiver service criteria. The case manager does not send Form 2065-B denying requests for specific services to providers.

The case manager must not cancel an active service authorization form identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, when the case manager completes Form 2065-B to deny a request for a service that did not meet the waiver service criteria.

9400  Service Suspensions

Revision 12-1; Effective May 1, 2012

§51.241

(a)
DADS or a provider must suspend an individual's MDCP services if or when:
(1)
the individual is admitted for purposes other than respite services to:
(A)
a hospital (if an RN or an LVN provides the services);
(B)
a nursing facility (if an RN or an LVN provides the services);
(C)
a state mental retardation facility;
(D)
a state mental health facility;
(E)
a rehabilitation hospital; or
(F)
an intermediate care facility for persons with mental retardation or related conditions; or
(2)
the individual or someone in the individual's residence exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the provider, or another person in the residence.
(b)
DADS or a provider may suspend an individual's MDCP services if the individual or someone in the individual's residence discriminates against a provider or a DADS employee.

The case manager or a provider may suspend an individual's MDCP services during the individual plan of care (IPC) period. The case manager or the provider must suspend MDCP services when the individual:

  • is admitted into a hospital;
  • is admitted into a nursing facility;
  • is admitted into a state supported living center;
  • is admitted into a state mental health facility;
  • is admitted into a rehabilitation hospital;
  • is admitted into an intermediate care facility for persons with intellectual disability or related conditions;
  • or someone in the individual's residence exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the provider's staff or another person in the residence;
  • or someone in the individual's residence discriminates against the provider's staff or DADS staff.

An individual or someone in the individual's residence may exhibit behavior that constitutes imminent danger or a threat to the health or safety of the individual or another person. Examples include, but are not limited to:

  • exhibiting weapons;
  • making direct or indirect threats of physical harm, force or death;
  • physically attacking a person with or without a weapon;
  • threatening use of force by self or someone else; and
  • sexual harassment or sexual assault.

Imminent danger in the context of requiring a suspension is not to be treated lightly, nor is it to be used loosely. Example: A medically fragile individual threatening to harm or kill someone when there are no weapons in the home and it would be physically impossible for the individual to carry out these threats, is not imminent danger and is not a cause for suspension. However, an individual or another person in the individual's residence brandishing a weapon, or having a history of physical violence and making threats that the individual or other person in the individual's residence is clearly capable of carrying out, may be imminent danger.

If, during any contact, the case manager perceives an individual's/family's comment or behavior to be threatening, hostile or of a nature that would cause concern for the safety of the individual, a provider employee or the case manager, he must immediately notify his supervisor. Regional management will review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the individual's safety may be at risk, the case manager must contact the Department of Family and Protective Services and the police, if appropriate, the same day the case manager is aware of the suspension. If the case manager believes there is a potential threat to others, regional management should determine the best method for notifying the provider and for addressing the individual's needs without placing the case manager at risk.

An individual who threatens his own health or safety or that of others should be considered for referral to the Local Authority and the police, if appropriate.

If a placement in an institution is determined to be permanent, the case manager must deny MDCP services following Section 9500, Service Denials and Case Closures.

The case manager may suspend MDCP services up to 180 days.

The case manager must document all contact with the individual, primary caregiver and provider using Form 2405, Narrative Notes, in the case file.

9410  Notification of Service Suspensions

Revision 12-3; Effective November 1, 2012

§51.419

(a)
Required service suspensions. A provider must suspend services to an individual if or when:
(1)
the individual is admitted for purposes other than respite services to:
(A)
a hospital (if the services are provided by an RN or an LVN);
(B)
a nursing facility (if the services are provided by an RN or an LVN);
(C)
a state mental retardation facility;
(D)
a state mental health facility;
(E)
a rehabilitation hospital; or
(F)
an intermediate care facility for persons with mental retardation or related conditions; or
(2)
someone in the individual's residence exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the provider, or another person. If this occurs the provider must make an immediate referral to:
(A)
DFPS or other appropriate protective services agency;
(B)
local law enforcement; and
(C)
the case manager.
(b)
Other service suspensions. A provider may suspend services to an individual if the individual or someone in the individual's residence discriminates against a provider or a DADS employee.
(c)
Notification of service suspension. The provider must notify the case manager orally or by fax about a service suspension no later than one working day after services are suspended. If the provider's notification is oral, the provider must send written notification to the case manager within five working days of the first notification.
(d)
Notification requirements. The notification must include:
(1)
the date of service suspension;
(2)
the reason for the suspension;
(3)
the duration of the suspension, if known; and
(4)
an explanation of the provider's attempts to resolve the problem that caused the suspension, including the reason why the problem was not resolved. This subparagraph applies only to circumstances described in subsections (a)(2) and (b) of this section.

DADS requires the provider to notify the case manager no later than one working day after services are suspended of the reason for the suspension, the effective date of the suspension and the duration, if known, for service suspensions initiated by the provider. An explanation of the provider's attempts to resolve the issues that initiated the suspension must be included.

When a case manager receives notice from the provider that services are suspended due to imminent danger to the health and safety of the service provider's staff, a referral to the Department of Family and Protective Services and the police (if appropriate) must be made the same day the case manager is aware of the suspension. By the next working day, the individual must be notified of the temporary suspension by means of Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. This notice must include a reference to 40 Texas Administrative Code §51.241(b), the effective date, which is the date the case manager became aware of the action, as well as a clear statement in the comments, such as "Your Medically Dependent Children Program services have been temporarily suspended due to ... You will be contacted by your case manager to determine if this problem can be resolved." The case manager must contact the individual and try to resolve the problem within 12 days from the date on the Form 2065-C. If the problem cannot be resolved, the provider may report to DADS that it will no longer serve the individual due to health and safety concerns. DADS may initiate services with a new provider or terminate the individual’s services.

For any situation requiring waiver service suspension, the case manager notifies the individual and provider by completing Form 2065-C using applicable citations in Attachment F, MDCP Suspension Citations/Codes, by the next working day upon becoming aware of the need for the suspension. If the individual or provider is aware of the return date from an institution, the case manager identifies the duration of the suspension on the comments section of Form 2065-C.

9420  Extension of Suspension

Revision 12-1; Effective May 1, 2012

MDCP services must be suspended as outlined in Section 9410, Notification of Service Suspensions. DADS may extend a suspension for an additional 30 days if the reason for the individual's suspension will exceed 180 days.

If the individual or family member clearly indicates the wish for MDCP services to resume, the case manager must review the reasons for the request to determine if an exception should be submitted to state office staff. Reasons or conditions that may be included in a request to continue MDCP services will depend on the reason for the suspension. Some examples of reasons for extending the suspension period for individuals:

  • residing in an institution:
    • documentation or verbal communication from a treating professional that demonstrates the individual will be able to return to his home in the community within 30 days of exceeding the 180 suspension period.
    • proof of having a home in the community to live in upon discharge from the institution.
    • resources in the community (for example, involved family) that will be available to help support the individual when he moves back into the community.
  • living or traveling out of state:
    • confirmation of having made a rental deposit for a home/apartment.
    • evidence that the barriers previously preventing the individual from returning to Texas now have been eliminated (for example, individual has identified a residence in Texas; individual will soon be discharged from an out-of-state institution).

If, in the case manager's judgment, there is clear and convincing evidence the individual can resume service within 30 days after he exceeds the 180-day suspension period, the case manager may request an exception by submitting a letter outlining the request and the circumstances to the unit manager, Community Services Policy and Curriculum Development Unit, Community Services and Program Operations Section, Mail Code W-351.

9430  Resuming Services

Revision 12-1; Effective May 1, 2012

§51.419

(e)
Resuming services after a suspension. The provider must resume services after a suspension:
(1)
on the date specified in writing by the case manager;
(2)
upon the individual's return home from an institution listed in subsection (a)(1) of this section; or
(3)
on the date the provider becomes aware of the individual's return home.

The duration of the suspension may depend on the reason for the suspension, such as the individual requiring an extended stay in a hospital or nursing facility. If the case manager was not aware or documented the duration of the suspension on Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, as indicated in Section 9410, Notification of Service Suspensions, the case manager must communicate with the provider or individual to obtain a date to resume services.

DADS requires providers resume services after a suspension:

  • upon the individual's return home from:
    • a hospital;
    • a nursing facility;
    • a state supported living center;
    • a state mental health facility;
    • a rehabilitation hospital;
    • an intermediate care facility for persons with intellectual disability or related conditions;
  • on the date the provider becomes aware of the individual's return home; or
  • on a date specified in writing by the case manager.

The case manager must complete Form 2065-B, Notification of Waiver Services, to notify the individual and provider to resume services if the case manager does not document the duration of the suspension on Form 2065-C. The case manager completes and sends Form 2065-B to the individual and provider within two working days:

  • of becoming aware of the individual's return to his residence with the effective date the same date as the individual's return; or
  • after resolving the reckless behavior or discrimination issues that lead to the suspension with the effective date the day the case manager completes the form.

If the individual's services are suspended when the annual reassessment is due, the case manager may conduct the annual reassessment with the individual and primary caregiver if it is likely participation in MDCP will continue. The case manager develops the annual reassessment individual plan of care (IPC) and applies the end date as if there had been no suspension and MDCP services were continued. Example: The IPC period is June 1, 2010, through May 31, 2011. The individual's services are suspended on April 15, 2010, and are reinstated July 10, 2011. The new IPC period is July 10, 2011 through May 31, 2012. The case manager must prorate the IPC cost limit using age out procedures in Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age.

The case manager must document all contact with the individual, primary caregiver and provider in the case file, using Form 2405, Narrative Notes.

9440  Procedures for Temporary Nursing Facility Admissions

Revision 12-1; Effective May 1, 2012

When an individual enters a nursing facility (NF) and the facility submits admission paper work, the transmission will automatically populate an end date in the Service Authorization record in the Service Authorization System (SAS). The end date is date of the NF admission. The case manager must determine if the individual's admission is temporary by contacting the primary caregiver. If it is likely the individual's NF admission is for long-term care, see Section 9541, Additional Procedures for Permanent Nursing Facility Admissions, to initiate case closure procedures. If the individual's NF admission is temporary, the case manager must data enter Code 35 for a temporary NF stay in the Termination Code field in all Service Authorization records.

MDCP Service Authorization records in SAS may be closed by an automated process before the case manager learns of and updates SAS records. When the NF submits Form 3618, Resident Transaction Notice, and the Minimum Data Set (MDS) for an MDCP individual, all MDCP Service Authorization records are updated with the new end date. The automated batch process runs five times weekly and uses the date on Form 3618, Item 11, to close the MDCP Service Authorization records effective the date of NF entry. A daily report is posted to the Claims Management Project Documents website at: http://dadsview.dads.state.tx.us/cms/projectdocs/Production/CS%20SRV%20Ended%20by%20NF%20 Enrollment.txt?PROJ_ID=T2R&DocTyp=Reports&s_PROJ_ID=T2R. Regional Claims Management System (CMS) coordinators will access the reports and notify MDCP case managers of individuals whose Service Authorization records are closed by the batch process.

Although Service Authorization records will be closed by the automated batch process, the case manager must still complete the Code 35 SAS action, which includes an additional manual step to prorate units before submitting the Service Authorization record. The case manager must follow procedures in Section 5140, Provider Transfers During the Plan of Care (IPC) Period, to update the number of units in the Service Authorization records for the period before the NF admission. The case manager must follow procedures in Section 4230, Service Authorization System (SAS), for SAS data entry time frames.

Upon discharge from the NF, the case manager creates new Service Authorization records with the remaining authorized service units. The begin date is the date of the NF discharge and the end date is the same as the IPC period. The total units entered in SAS for the IPC period must not exceed the IPC cost limit. The case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan.

Example: An applicant is certified for services effective May 15, 2010, through May 31, 2011. He enters an NF on Feb. 25, 2011. The NF submits Form 3618 and the MDS and SAS automatically end dates MDCP Service Authorization records effective Feb. 25, 2011. The case manager enters Code 35 in the Termination Code field in SAS and updates the Units field with information given by providers. The individual remains in the NF through March 31, 2011. The case manager will create new Service Authorization records with a begin date of March 31, 2011, and end date May 31, 2011, with the remaining balance of authorized service units.

Developing an Annual Reassessment During the Suspension Period

The individual may be residing in the NF when the annual reassessment is due. In this circumstance, the case manager may conduct the annual reassessment in the NF without considering this a new enrollment provided all program requirements are met. The case manager must meet with the individual and primary caregiver to assure the appropriateness of the IPC. Service coordination is essential to assure the new IPC is adequate to meet the individual's needs in the community and is within the cost limit. If the individual is discharged from the NF after the IPC expires, the effective date of the IPC is the date of discharge. The IPC end date remains the same as if the IPC had not expired and MDCP services were continued.

Example: The IPC period is Feb. 1, 2010, through Jan. 31, 2011. The individual enters the NF on Dec. 15, 2010, and is discharged March 10, 2011. The individual meets all MDCP criteria on the discharge date of March 10, 2011. The new IPC period is March 10, 2011 through Jan. 31, 2012. The case manager must prorate the IPC cost limit using age out procedures in Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age.

A Code 35 SAS action is not required for an individual whose services are suspended for other reasons identified in Section 9400, Service Suspensions.

9500  Service Denials and Case Closure

Revision 12-1; Effective May 1, 2012

§51.243

(b)
Service denials. DADS may deny services to an individual when:
(1)
the individual no longer meets the eligibility requirements described in §51.203 of this chapter (relating to Eligibility Requirements);
(3)
the individual's primary caregiver does not participate in the development of the IPC; or
(4)
budgetary constraints require cost reductions
(c)
Case closure. DADS closes an individual's case if:
(1)
the individual no longer meets the eligibility requirements described in §51.203 of this chapter;
(2)
the individual dies;
(3)
the individual enters an institution for long-term care purposes;
(4)
the individual starts receiving services through another §1915(c) waiver program;
(5)
the individual does not use MDCP services for 60 or more consecutive days without prior approval from the case manager;
(6)
the individual's primary caregiver does not participate in the development of the individual's IPC; or
(7)
the individual request that services end.

The case manager must follow procedures in Section 4230, Service Authorization System (SAS), for SAS data entry procedures for case closures. Consult the SAS help file for SAS record data entry procedures for termination actions.

9510  Ineligibility

Revision 12-1; Effective May 1, 2012

An applicant may be denied MDCP services if he does not meet the established eligibility criteria noted in Section 1300, Eligibility. An individual may also be denied MDCP services if he no longer meets the same eligibility criteria in Section 1300 with the exception of disability criteria in Section 1350, Disability, as determined through the annual reassessment process.

If the applicant does not meet the initial eligibility criteria, the case manager notifies him of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment D, MDCP Application Denial Citations, of Form 2065-C instructions to complete the Comments part of the form. The case manager signs and dates Form 2065-C to document program ineligibility and sends Form 2065-C within two working days of the determination.

If the individual does not meet eligibility criteria at the annual reassessment, the case manager notifies him and providers of program ineligibility by completing Form 2065-C. The case manager uses Attachment E, MDCP Denial Citations/Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager signs and dates Form 2065-C to document program ineligibility and sends Form 2065-C within two working days of the determination to the individual and providers. The case manager must send Form 2065-C to the individual no later than 30 days before the end of the individual's IPC period. The day the case manager completes Form 2065-C is day zero and starts the 30-day time frame for the notification period.

The case manager does not complete any service authorization forms when denying MDCP services for an initial application or for an individual at the annual reassessment.

For case closures resulting from loss of Medicaid, see Section 5500, Loss of Medicaid.

For individuals whose Medicaid eligibility is based on ME-Waivers, the case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) by sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center by fax within two working days of the program ineligibility determination.

9520  Failure to Maintain Enrollment

Revision 13-2; Effective May 1, 2013

§51.219

(a)
To maintain enrollment in MDCP, the individual or the individual's parent or guardian must:
(1)
participate in the development and implementation of the IPC;
(3)
use MDCP services as described in the IPC;
(4)
select the provider;
(5)
provide training, monitor, and supervise the provider; and
(6)
keep in the residence the most recent seven days of service delivery documentation as referenced in §51.503 of this chapter (relating to In-Home Record) and make it available to DADS upon request.
(b)
An individual may lose eligibility for MDCP if the individual or the individual's parent or guardian fails to comply with the requirements in subsection (a) of this section.

An individual may lose eligibility for MDCP if the individual or the individual's parent/guardian does not:

  • participate in the development and implementation of the individual plan of care (IPC);
  • use MDCP services as described in the IPC;
  • select the provider;
  • provide training, monitor and supervise the provider;
  • keep in the residence the most recent seven days of service delivery documentation in the In-Home Record and make it available to DADS upon request; or
  • allow an attendant to record hours worked through Electronic Visit Verification (EVV) either by the use of their home phone or a Fixed Visit Verification (FVV) device when required.

Maintaining enrollment requirements are addressed in Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, and are essential for the development and implementation of services for the individual and primary caregiver. Individual and family responsibilities promote service planning and IPC implementation.

If the individual or the individual's parent/guardian does not fulfill the maintaining enrollment responsibilities, the case manager must attempt to resolve the issue, which may place the individual's MDCP eligibility at risk. The case manager must inform the individual or the individual's parent or guardian failure to maintain enrollment actions significantly impact service planning or IPC implementation and will place the individual at risk for losing MDCP services.

The case manager must document all contacts and attempted contacts to the individual/family in the case file on Form 2405, Narrative Notes. The case manager must consult with his supervisor to determine if case closure procedures should be implemented. If continuation of actions impact the case manager's responsibility to develop a service plan or the individual goes without services due to the failure to maintain enrollment, the case manager may proceed with denial of MDCP services. The case manager notifies the individual and providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations and Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager must complete and send Form 2065-C and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of determining loss of eligibility due to failure to maintain enrollment. The effective date of Form 2065-C and applicable service authorization forms is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period.

9530  Death of Individual

Revision 12-1; Effective May 1, 2012

After learning of the death of an individual, the case manager must send Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, and all applicable service authorization forms, to the provider within two working days of verifying the case should be closed. A copy of Form 2065-C must be sent to the MEPD staff, if appropriate. The case manager must not send a denial notification to the family or primary caregiver. The effective date on Form 2065-C and service authorization forms is the individual's date of death.

If the individual was receiving Supplemental Security Income (SSI) and the eligibility records reflect that the SSI has been denied, the case manager uses the same effective date of denial as the SSI denial date. If the eligibility records reflect the SSI is still active, the case manager must contact the Social Security Administration to notify it of the date of the individual's death.

9540  Institutional Placement

Revision 12-1; Effective May 1, 2012

When an individual is admitted in an institution for long-term care purposes, he is no longer eligible for MDCP services and services must be terminated. An institution may be:

  • a hospital;
  • a nursing facility;
  • a state supported living center;
  • a state mental health facility;
  • a rehabilitation hospital; or
  • an intermediate care facility for persons with intellectual disability or related conditions.

The case manager notifies the individual and providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations/Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager must complete and send Form 2065-C and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the provider within two working days of determining loss of eligibility due to institutional placement. The effective date of Form 2065-C and applicable service authorization forms is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period.

The case manager does not update or complete any service authorization forms when denying MDCP services for an individual in an institution if the effective date of the denial coincides with the end of an individual plan of care (IPC) period.

For individuals whose Medicaid eligibility is based on ME-Waivers, the case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) by sending Form H1746-A, by fax within two working days of the program ineligibility determination. The case manager must indicate on Form H1746-A the individual lost eligibility based on institutional placement and include a copy of Form 2065-C.

9541  Additional Procedures for Permanent Nursing Facility Admissions

Revision 12-1; Effective May 1, 2012

When an MDCP individual enters a nursing facility (NF) and the facility submits admission paper work, the transmission will automatically update the end date field in all MDCP Service Authorization records in the Service Authorization System (SAS). The end date is date of the NF admission. The case manager must determine if the individual's admission is for long-term care purposes by contacting the primary caregiver. If it is likely the individual's NF admission is temporary, see Section 9410, Notification of Service Suspensions, and Section 9440, Procedures for Temporary Nursing Facility Admissions, for suspension procedures. If the individual's admission is for long-term care purposes, the case manager will data enter Code 03, Admitted to Institution, in the termination field in all Service Authorization records and initiate case closure procedures.

The case manager notifies the individual and providers of program ineligibility following procedures in Section 9540, Institutional Placement; however, the effective date of Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, and applicable service authorization forms is the day of the NF admission.

MDCP Service Authorizations records in SAS may be closed by an automated process before the case manager learns of the individual's NF admission. When the NF submits Form 3618, Resident Transaction Notice, and the Minimum Data Set for an MDCP individual, all MDCP Service Authorization records are updated with the new end date. The automated batch process runs five times weekly and uses the date on Form 3618, Item 11, to close the MDCP Service Authorization records effective the date of NF admission. A daily report is posted to the Claims Management System (CMS) Project Documents website at: http://dadsview.dads.state.tx.us/cms/projectdocs/Production/CS%20SRV%20Ended%20by%20NF%20 Enrollment.txt?PROJ_ID=T2R&DocTyp=Reports&s_PROJ_ID=T2R. The Regional CMS coordinator will access the report and notify the case manager of individuals whose Service Authorization records are closed by the batch process.

Although Service Authorization records will be closed by the automated batch process, the case manager must still enter termination Code 03 to all MDCP Service Authorization records.

Reinstating MDCP Services Before the IPC Expires

If services were terminated when the individual entered the NF but the individual was discharged after fewer than 180 days and requests MDCP services again before the current IPC period would have ended, the case manager may reinstate MDCP services without considering this a new enrollment provided all program requirements are met. The case manager may need to meet with the individual and primary caregiver to assure the appropriateness of the service plan and is within the cost limit.

The case manager must update the Units field in the Service Authorization records for the periods before the NF admission and create new Service Authorization records for the period after the NF discharge. The total units entered in SAS for the individual plan of care (IPC) period must not exceed the IPC cost limit. The case manager must follow procedures in Section 5140, Provider Transfers During the IPC Period, to determine the number of units to enter in the Service Authorization records for the period before the NF admission.

Reinstating MDCP Services After the IPC Expired

If services were terminated when the individual entered the NF but the individual was discharged after fewer than 180 days and requests MDCP services again after the current IPC period expired, the case manager may reinstate MDCP services without considering this a new enrollment provided all program requirements are met. The case manager must meet with the individual and primary caregiver to assure the appropriateness of the service plan.

The case manager develops the IPC and applies the end date as if there had been no NF admission and MDCP services were continued. Example: The IPC period is Feb. 1, 2010, through Jan. 31, 2011. The individual enters the NF on Dec. 15, 2010, and is discharged March 10, 2011. The individual meets all MDCP criteria on the discharge date of March 10, 2011. The new IPC period is March 10, 2011, through Jan. 31, 2012. The case manager must prorate the IPC cost limit using age out procedures in Section 5130, Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age.

Re-enrolling Into MDCP on or After 180 Days From the NF Admission

If services were terminated due to the NF admission and the individual was discharged on or after 180 days from the admission date and requests MDCP services, the case manager may re-enroll the individual following procedures in Section 3500, Money Follows the Person Option.

9550  Aging Out

Revision 13-2; Effective May 1, 2013

§51.203

To be eligible to participate in MDCP, a person must:

(3)
be under 21 years of age;

In Section 1330, Age, an applicant/individual must be under the age of 21 to be eligible for MDCP services. If the case manager is in the process of enrolling an applicant who will turn 21 before the end of the individual plan of care (IPC) period, the case manager must inform the applicant of the transition process. On the day of the individual's 21st birthday, he ages out of MDCP and is no longer eligible. The individual may receive MDCP services through the day before his 21st birthday.

An applicant in a non-managed care area who is not enrolled in MDCP before his 21st birthday is not eligible to transition into the Community Based Alternatives (CBA) program.

An applicant in a managed care area who has not been Medicaid certified and is not enrolled in MDCP before his 21st birthday is not eligible to transition into the STAR+PLUS Waiver (SPW) program.

An applicant in a managed care area who is Medicaid certified has two options to enroll into the SPW program. An applicant with Medicaid may voluntarily enroll in STAR+PLUS to receive acute care services (including attendant and Day Activity and Health Services) and request SPW services after his 21st birthday. If the applicant does not voluntarily enroll in STAR+PLUS before his 21st birthday, he will be automatically enrolled on his 21st birthday. The applicant may then request SPW services. In a managed care area, SPW services are only available to Medicaid recipients age 21 or over. An applicant in a managed care area may have a delay in receiving SPW services after his 21st birthday if he is not enrolled directly from MDCP.

For these reasons, DADS staff must make every effort to timely process an enrollment for a 20-year old applicant. During the application process, the case manager must inform the applicant of the transition process. The case manager must also inform the designated regional complex needs coordinator as soon as possible when enrolling an applicant who will age out in less than 12 months.

An individual may apply to either the CBA or SPW programs, depending on the individual's service area. The individual may transition into the CBA or SPW program if he meets the eligibility requirements. The transition process to the CBA or SPW program begins one full year before the individual's 21st birthday. At age 21, individuals are not eligible for MDCP and will no longer be eligible for Private Duty Nursing (PDN), Skilled Nursing (SN) or Personal Care Services (PCS) through the Texas Health Steps (THS) Comprehensive Care Program (CCP). The case manager must inform the complex needs coordinator of an applicant or individual who may have high nursing needs as soon as possible.

State office will furnish a list of individuals turning 21 in the proceeding 18 months to regional directors who will distribute it to the regional complex needs coordinator and designated staff as applicable. The list includes MDCP individuals as well as Medicaid recipients who receive PDN, SN and PCS through CCP. The complex needs coordinator or other designated staff will identify all MDCP individuals aging out one full year before their 21st birthday. At any time during the transition process, the complex needs coordinator may request documentation and assistance from the case manager.

In order to assist the individual/family with the transition to CBA or SPW, the case manager must monitor the transition every three months during the year before the transition while the individual is enrolled in MDCP. The case manager must complete the transition monitor contact within the calendar month of the three-month time frame. It is possible the transition planning process may not coincide with the individual's IPC period and service monitoring schedule. See Section 9551, Aging Out to the Community Based Alternatives (CBA) Program, or Section 9552, Aging Out to the STAR+PLUS Waiver Program, for transition procedures.

Since the individual's 21st birthday is known, the case manager must notify him of loss of program eligibility due to age by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The case manager uses Attachment E, MDCP Denial Citations and Codes, of Form 2065-C instructions to complete the Comments part of the form. The case manager must complete and send Form 2065-C to the individual no later than 35 days before the individual's 21st birthday. The effective date of Form 2065-C is the day before the individual's 21st birthday.

Example: An individual's 21st birthday falls on June 29. The last day of MDCP eligibility is June 28th. The case manager completes Form 2065-C indicating the individual will no longer be eligible for MDCP services after June 28 of the current year and mails the form no later than May 24 of the current year.

The case manager does not need to send a copy of Form 2065-C or applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the provider(s). The end date of the notification forms and applicable service authorization forms for the current IPC period must be the day before the individual's 21st birthday.

The case manager may remind providers by telephone or by sending a copy of Form 2065-C or Form 2067, Case Information, of the individual's program ineligibility due to age.

The case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) staff when a Medicaid ME-Waivers individual ages out of MDCP. The case manager must notify MEPD by sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center for an individual whose Medicaid eligibility is established by MEPD. The case manager must include the date of enrollment into CBA or SPW, as applicable. The case manager must notify MEPD the same day the case manager sends the aging out notification to the individual.

9551  Aging Out to the Community Based Alternatives (CBA) Program

Revision 12-2; Effective August 1, 2012

An individual who is aging out of the program and lives in a non-managed care area may apply for the CBA program to continue to receive community services and avoid institutionalization on or after his 21st birthday. The transition planning begins one year before the individual's 21st birthday. The MDCP case manager, the CBA case manager and the DADS regional nurse conduct a home visit to review services available through CBA. With the active assistance from the MDCP case manager, the CBA case manager will facilitate the individual's transition to the CBA program.

The CBA case manager will follow slightly different transition procedures for individuals identified as a "high needs individual" based on nursing needs and projected cost of CBA services. The MDCP case manager must participate in any team meetings to facilitate the high needs individual's transition to CBA. The MDCP case manager must assist the CBA case manager as needed for both the high needs and non-high needs individual.

Prior to the 12-month visit, the MDCP case manager must send the individual the Initial Age-out Letter found in Appendix XIX, Age Out Timeline, Progress Logs, Letters and Talking Points. This letter will serve as an introduction to the process and advise the individual/parent to expect the contact from DADS staff to schedule the 12-month visit. Also before the 12-month CBA transition home visit, the MDCP case manager must forward a copy of the individual's Form 2410, Medical-Social Assessment and Individual Plan of Care, as well as Form 2411, Interim Plan of Care, and/or Form 2412, Budget Revision, if an IPC change was completed, and the individual's most recent Medical Necessity and Level of Care (MN/LOC) Assessment to the CBA case manager.

12 Months Before the Individual's 21st Birthday

One year before the MDCP individual's 21st birthday, the CBA case manager will contact the MDCP case manager and DADS regional nurse to coordinate the home visit. At the home visit, the CBA case manager will review CBA services and advise the individual/family the CBA intake process will begin six months before the individual's 21st birthday.

Nine Months Before the Individual's 21st Birthday

The MDCP case manager must contact the individual/family to review the transition to CBA. The MDCP case manager briefly reviews the materials reviewed and discussed at the 12-month home visit with the individual/family. The MDCP case manager may contact the individual/family via a face-to-face visit or by telephone. The MDCP case manager contacts the CBA case manager to discuss any problems or concerns. The Follow-up Letter, found in Appendix XIX, is sent to any individuals who have 50 or more hours of skilled nursing services weekly. This letter will be sent to the individual by the CBA case manager assigned to the individual as a reminder that the aging out application process will begin six months prior to the individual’s 21st birthday.

Six Months Before the Individual's 21st Birthday

The CBA case manager will begin the CBA intake process. It is at this contact the CBA case manager may initiate the high needs process.

The MDCP case manager contacts the individual/family to review the transition to CBA. The MDCP case manager briefly reviews the materials reviewed and discussed at the 12-month home visit or issues identified in the previous contact with the individual/family. The MDCP case manager may contact the individual/family via a face-to-face visit or by telephone. The MDCP case manager contacts the CBA case manager to discuss any problems or concerns.

Three Months Before the Individual's 21st Birthday

The MDCP case manager must contact the individual/family to review the transition to CBA. The MDCP case manager briefly reviews the materials reviewed or discussed from the previous contacts with the individual/family. The MDCP case manager may contact the individual/family via a face-to-face visit or by telephone. The MDCP case manager contacts the CBA case manager to discuss any problems or concerns.

Before Aging Out of MDCP

The MDCP case manager notifies the individual of MDCP ineligibility due to aging out following procedures in Section 9550, Aging Out.

The case manager must document all required contacts during the age out of an individual on the Age Out Timeline and Progress Log found in Appendix XIX, and include it in the case file. The case manager must document any additional contacts with the individual/family, CBA case manager, and complex needs coordinator using Form 2405, Narrative Notes, and file in the case file.

9552  Aging Out to the STAR+PLUS Waiver Program

Revision 12-2; Effective August 1, 2012

An individual who is aging out and living in a managed care service area may apply for services through the Star+PLUS Waiver (SPW) program to continue to receive community services and avoid institutionalization on or after his 21st birthday. It is the case manager's responsibility to facilitate the individual's transition to the SPW program.

Before Initial Transition Home Visit

Prior to the 12-month visit, the MDCP case manager must send the individual the Initial Age-out Letter found in Appendix XIX, Age Out Timeline, Progress Logs, Letters and Talking Points. This letter will serve as an introduction to the process and advise the individual/parent to expect the contact from DADS staff to schedule the 12-month visit. Also before the face-to-face visit to begin the transition process, the case manager must request SPW enrollment packets from the STAR+PLUS Support Unit (SPSU). If multiple transition visits are planned, the case manager should identify the number of enrollment packets needed.

12 Months Before the Individual's 21st Birthday

The case manager must schedule a face-to-face visit with the DADS regional nurse, the individual and primary caregiver to initiate the transition process.

During the home visit to the individual and his family, the case manager must present an overview of SPW and the changes that will take place on the individual's 21st birthday. The case manager must present and review Appendix XIX with the individual/family. The points to be discussed are:

  • The individual will no longer be eligible for MDCP or Comprehensive Care Program (CCP) services, including nursing services, beginning at midnight of his 21st birthday.
  • SPW services are an option available to the individual at age 21. The case manager also presents an overview of the array of services available within SPW.
  • The SPW enrollment packet is presented to the individual and reviewed. The packet contains a managed care organization (MCO) list in the service area and a comparison chart to assist the individual in making a selection. The individual will choose an MCO in his service area that will perform the assessment for services and oversee the delivery of services.
  • The importance of choosing an MCO six months before the 21st birthday in order to avoid being assigned an MCO or having a gap in services.
  • The individual can change MCOs anytime after the first month of enrollment.
  • SPW has a cost limit based on a medical assessment, the Medical Necessity/Level of Care (MN/LOC) Assessment. The assessment results in the cost limit for the annual service plan.
  • To be eligible for SPW services, an individual plan of care (IPC) must be developed within the cost limit that will meet the individual's needs and ensure health and safety.
  • If an IPC cannot be developed within the cost limit that ensures health and safety, the SPW application will be denied.
  • The IPC considers all resources available to meet the individual's needs, including community supports, other programs, and what the individual's informal support system can provide to meet the individual's needs.
  • The SPW application procedures will begin six months before the individual's 21st birthday. The SPSU will contact the individual to begin the application process and find out which MCO has been selected. If an MCO has not been selected, then 30 days is allowed for a selection. After 30 days, an MCO is selected for the individual.
  • After the MCO is selected, the MCO service coordinator will contact the individual to begin the assessment for services and assist the individual/family in identifying and developing additional resources and community supports to help meet the individual's needs.
  • The MCOs contract with providers that do not typically have nurses available for daily nursing care. The individual/family may need to identify nurses who are willing to work with the individual.
  • The case manager monitors the individual's transition every 90 days until the individual turns 21.

The provider will assist the individual in determining the services needed within this service array to meet his needs and ensure health and safety. For example: If other needs are met, but the individual primarily requires nursing, then a plan can be developed with the maximum number of nursing hours within the cost limit while the individual's other needs are met through other resources.

Reassure the family that every effort will be made to help them make a successful transition to SPW and develop a plan that will meet the individual's needs.

During the transition process, the case manager will:

  • monitor the service planning with the individual/family every three months during the year before the individual ages out;
  • contact the SPSU to discuss any problems or concerns; and
  • advise the regional complex needs coordinator and the SPSU of a high needs individual.

Nine Months Before the Individual's 21st Birthday

The case manager contacts the individual/family to review the transition to SPW. The case manager briefly reviews the materials reviewed and discussed at the 12-month face-to-face visit with the individual/family. The case manager may contact the individual/family via a face-to-face visit or by telephone. The case manager contacts the SPSU to discuss any problems or concerns. The Follow-up Managed Care/STAR+PLUS Waiver Letter, found in Appendix XIX, is sent to any individuals in managed care areas who have 50 or more hours of skilled nursing services weekly and will be assessed for SPW. This letter will be sent to the individual by the MDCP case manager assigned to the individual as a reminder that the aging out application process will begin six months prior to the individual’s 21st birthday.

Six Months Before the Individual's 21st Birthday

The case manager contacts the individual/family to review the transition to SPW. The case manager briefly reviews the materials reviewed and discussed at the 12-month face-to-face visit or issues identified in the previous contact with the individual/family. The case manager may contact the individual/family via a face-to-face visit or by telephone. The case manager contacts the SPSU to discuss any problems or concerns.

The case manager must make a referral to the SPSU six months before the individual's 21st birthday. To refer the individual, the case manager must complete Form 2067, Case Information, and include the following information:

  • the individual's name;
  • the individual's Medicaid number;
  • the individual's date of birth; and
  • a statement identifying the individual's last day on MDCP and he should be contacted regarding SPW services.

The SPSU will:

  • identify all MDCP individuals aging out in six months;
  • contact the individual/family by telephone to:
    • review the packet discussed at the 12 month transition visit;
    • inform the individual/family they have 30 days to choose an MCO;
    • explain if the individual/family does not choose an MCO, an MCO will be selected for the individual by the state by rotational basis; and
    • explain the individual/family can change MCOs anytime after the first month of enrollment; and
  • notify Health and Human Services Commission staff, DADS Access and Intake in state office, and the regional complex needs coordinator of all possible high needs situations.

SPSU Responsibilities Five Months Before the Individual's 21st Birthday

Within 30 days following the SPSU's initial telephone contact, the SPSU contacts the individual/family to obtain the name of the selected MCO.

If the individual/family has selected an MCO, the individual/family should inform the SPSU of their choice. SPSU will inform the:

  • individual/family they must remain with the selected MCO through the first month of SPW services to assure a smooth transition and service continuity; and
  • MCO of individual's choice.

If the individual/family has not selected an MCO, the SPSU will inform the individual/family if an MCO is not selected within seven calendar days, one will be assigned. If the individual/family does not make a selection within the seven calendar days, the SPSU will select an MCO for the individual by rotational basis. The SPSU will inform the individual/family:

  • the state has selected an MCO; and
  • they must remain with the MCO through the first month of SPW services to assure a smooth transition and service continuity.

The SPSU will also inform the MCO of the individual's choice.

The MCO will schedule a home visit with the individual/family within 14 days of the SPSU notification of choice of MCO.

Three Months Before the Individual's 21st Birthday

The case manager contacts the individual/family to review the transition to SPW. The case manager briefly reviews the materials reviewed or discussed from the previous contacts with the individual/family. The case manager may contact the individual/family via a face-to-face visit or by telephone. The case manager contacts the SPSU to discuss any problems or concerns. If the individual/family did not select an MCO and one was assigned, the case manager must inform the individual/family they may change the assigned MCO after the first calendar month.

Before Aging Out of MDCP

The case manager notifies the individual of MDCP ineligibility due to aging out following procedures in Section 9550, Aging Out.

The case manager must document all required contacts during the age out of an individual on the Age Out Timeline and Progress Log, found in Appendix XIX, and include it in the case file. The case manager must document any additional contacts with the individual/family, SPSU, and complex needs coordinator using Form 2405, Narrative Notes, and file in the case file.

9560  Interest List Releases to Other Waiver Programs

Revision 12-1; Effective May 1, 2012

§51.211

(g)
An individual may be enrolled in only one §1915(c) waiver program at a time.

An individual may be registered on other waiver program interest lists and may be released from the interest list before the individual ages out of MDCP. When an individual is enrolled in another 1915(c) waiver program, he is no longer eligible for MDCP services. In Texas, the following are 1915(c) waiver programs:

  • Community Based Alternatives (CBA)
  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services (HCS)
  • Texas Home Living (TxHmL)
  • STAR+PLUS Waiver (SPW)

When notified the individual is in the enrollment process for another waiver, the MDCP case manager must work with the enrolling case manager/service coordinator to minimize the risk of service gaps. Once the enrollment date into the other waiver program is determined, the MDCP case manager must close the case. The effective date of MDCP case closure is one day before the enrollment date of the other waiver program. The MDCP case manager notifies the individual and MDCP providers of program ineligibility by completing Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services. The MDCP case manager uses Attachment E, MDCP Denial Citations/Codes, of Form 2065-C instructions to complete the Comments part of the form. The MDCP case manager must complete and send Form 2065-C and applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures, to the individual and the MDCP provider within two working days of determining loss of eligibility due to enrollment into another waiver program. The effective date of Form 2065-C and applicable service authorization forms is 30 days after the date on the individual's notification letter. The day on the individual's notification letter is day zero and starts the 30-day time frame for the notification period.

If the enrollment date into the other waiver program does not allow for the 30-day notification time frame for a case closure action, the MDCP case manager may follow Section 9110, Exceptions to the 30-day Notification Time Frame.

The MDCP case manager must notify Medicaid for the Elderly and People with Disabilities (MEPD) when a Medicaid ME-Waivers individual enrolls into another waiver program. The MDCP case manager must send Form H1746-A, MEPD Referral Cover Sheet, to the Midland Document Processing Center to notify MEPD that the individual is terminating from MDCP and enrolling into another waiver program. The MDCP case manager must identify the other waiver program. The MDCP case manager must notify MEPD the same day the case manager sends the notification to the individual.

9570  Transfer of an Individual to Another Service Area

Revision 12-1; Effective May 1, 2012

When an active individual moves from one MDCP service area to another, the case must remain open and the existing individual plan of care (IPC) remain in effect until a new plan is implemented. The case manager in the service area of origin is the "original" case manager and the case manager in the new service area is the "new" case manager.

Due to unknown factors that may arise in the process of transferring an individual from one service area to another, coordination between the original and new case manager is important. As information affecting the individual's transfer becomes available, both case managers must keep each other and other entities informed. For this reason, direction in Section 9571, Procedures for the Original Case Manager, and Section 9572, Procedures for the New Case Manager, provide a general chronological guideline, except as noted, to assist the original and new case manager. Every effort must be made to minimize a gap in service delivery.

9571  Procedures for the Original Case Manager

Revision 12-1; Effective May 1, 2012

When the individual notifies the case manager that he is moving to another service area, the case manager must request a projected date of transfer and any information the individual may have to assist with the case transfer process, such as the new address, telephone number or a point of contact for the individual in the new service area. It is the case manager's responsibility to:

  • contact the office in the new service area to obtain the new case manager's name, address and telephone number;
  • contact the new case manager by telephone or email to provide the individual's name, Medicaid number, new address and telephone number, if available, whether or not the individual will have a change in primary caregiver(s), and other identifying information; and
  • request a provider choice list from the new case manager for the services identified in the individual's individual plan of care (IPC).

The case manager must provide the individual with the new case manager's name and telephone number. The case manager must inform the individual he may elect to remain with the current provider, if available in the new service area, or provide the individual with the provider choice list and have the individual select a new provider. The case manager must also notify the individual if a provider is not chosen quickly and it is near the end of the IPC period, a gap in services may occur.

When the case manager receives the projected date of transfer, the case manager must follow procedures in Section 5140, Provider Transfers During the IPC Period, to obtain the amount of services the provider will deliver up to the date of transfer. The case manager must complete and send Form 2065-B, Notification of Waiver Services, to terminate the provider's service authorization. The case manager must also update applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures. The termination date of Form 2065-B and cancellation date on applicable service authorization forms is the date before the transfer date. The case manager must complete and send Form 2065-B and applicable service authorization forms to the individual and the provider within two working days of receipt of service delivery information from the losing provider.

Once the individual has selected a provider for service delivery in the new service area, it is the case manager's responsibility to:

  • communicate the individual's provider choice to the new case manager with a projected date of transfer;
  • fax a copy of Form 2410, Medical-Social Assessment and Individual Plan of Care, to the new case manager;
  • fax a copy of a Form 2411, Interim Plan of Care, and/or Form 2412, Budget Revision, to the new case manager if an IPC change was completed during the current IPC period;
  • forward the service delivery information from the losing provider(s) to the new case manager; and
  • inform the new case manager of the transfer date.

For an individual accessing the Consumer Directed Services (CDS) option, the case manager and the new case manager must coordinate service delivery in the new service area with the existing CDS agency. It is possible the CDS agency may serve the new service area or may address service delivery for a temporary transfer directly with the CDS employer. The individual transfer procedure may vary based on the type of transfer and the needs of the caregiver in the new service area.

Service Authorization System (SAS) Records

The case manager must update all applicable SAS records except as noted below. The case manager must use the information provided by providers to update the Units and End Date fields for all Service Authorization records (if there is a change in providers). The case manager must update the End Date field in the Authorizing Agent record. The end date is the day before the transfer date.

The case manager must obtain the provider information from the new service area and use the remaining units in the service plan to create new Service Authorization records. Consult the SAS help file for Provider Transfers to update Service Authorization records for case transfer actions.

Unless information is incorrect, the case manager does not need to update the following SAS records:

  • Address
  • Location
  • Phone
  • Enrollment
  • Service Plan
  • Applied Income/Copay
  • Level of Service
  • Diagnosis
  • Medical Necessity

The case manager must document all contact with the individual/primary caregiver, provider(s) and new case manager using Form 2405, Narrative Notes, in the case file. The case manager must mail the case file to the new case manager within three working days of confirming the move.

9572  Procedures for the New Case Manager

Revision 12-1; Effective May 1, 2012

When the case manager is notified an individual is moving or has moved to the new service area, it is the case manager's responsibility to:

  • contact the original case manager to notify him of the individual's move or intent to move and provide the individual's new address and telephone number, if available;
  • request the individual's case file from the original case manager once the case manager has confirmed the move occurred;
  • request the individual's Medicaid type from the original case manager; and
  • send a provider choice list to the original case manager if the current provider does not serve the new area and the individual has not yet moved.

The case manager will contact the individual/family in the new service area to assess for any changes that might affect service delivery. If an individual transfers from one service area to another to spend time with a non-custodial parent or other relative, the new case manager must contact the parent or relative to establish primary caregiver status, review MDCP services and identify if an individual plan of care (IPC) change is needed.

If a change to the service plan is needed, the case manager may complete Form 2411, Interim Plan of Care, or Form 2412, Budget Revision. If a change in the IPC is needed, the effective date of the IPC change is the date of transfer.

Once the case manager has negotiated the start of care, the case manager must complete Form 2065-B, Notification of Waiver Services, to the individual and providers. The case manager must also complete applicable service authorization forms identified in Section 9100, Notification Forms for Service Reductions, Suspensions, Denials and Case Closures. The effective date of Form 2065-B and applicable service authorization forms is the transfer date.

The case manager must complete and send Form 2065-B, applicable service authorization forms, Form 2410, Medical-Social Assessment and Individual Plan of Care, Form 2411 (if applicable) and Form 2412 (if applicable) to the individual and the provider within two working days of receipt of service delivery information from the losing provider.

If the change to the IPC results in a reduction in services, the case manager follows procedures in Section 9200, Service Reductions. If the change to the IPC results in a case closure, the case manager follows procedures in Section 9500, Service Denials and Case Closure.

For an individual accessing the Consumer Directed Services (CDS) option, the case manager and the original case manager must coordinate service delivery in the new service area with the existing CDS agency. It is possible the CDS agency may serve the new service area or may address service delivery for a temporary transfer directly with the CDS employer. The individual transfer procedure may vary based on the type of transfer and the needs of the caregiver in the new service area.

For the individual whose financial eligibility is determined by Medicaid for the Elderly and People with Disabilities (MEPD), the case manager must notify MEPD of the individual's transfer by sending Form H1746-A, MEPD Referral Cover Sheet. The case manager must notify MEPD staff of all case transfers whether permanent or temporary.

For the individual whose financial eligibility based on Temporary Assistance for Needy Families (TANF)-related Medicaid determined by Texas Works staff, the household must report a change in address within 10 days from knowing of the change. All households are required to report residence changes. The case manager may assist the individual in reporting this change by completing Form H1019, Report of Change, and sending it to the local Texas Works office. The case manager may assist the individual notify Texas Works staff of all case transfers whether permanent or temporary.

Service Authorization System (SAS) Records

The case manager must access SAS to confirm the current service plan. The case manager must update the following SAS records:

  • Phone
  • Authorizing Agent
  • Case Ownership

If the transfer results in an IPC change, the case manager follows Section 5100, Changes to the Individual Plan of Care (IPC).

The case manager must document all contact with the individual/primary caregiver, provider(s), MEPD staff, Texas Works staff and original case manager using Form 2405, Narrative Notes, in the case file. If the individual is receiving SSI, the case manager will request the individual/family contact the Social Security Administration to report a change of address.

9600  Appeals and Fair Hearing Procedures

Revision 14-1; Effective February 3, 2014

§51.251

(a)
Appeals and hearings are conducted as described in 1 TAC Chapter 357 (relating to Medical Fair Hearings).
(b)
An individual may appeal a DADS action. In this section, a DADS action means a service suspension as described in §51.241 of this chapter (relating to Service Suspensions), or a service reduction, service denial, or case closure as described in §51.243(a), (b), and (c)(1)-(6) of this chapter (relating to Service Reductions, Service Denials, and Case Closures).
(c)
To appeal a DADS action, an individual must make a request for a hearing orally or in writing to the case manager within 90 days from the date on the notice of the DADS action.
 
(e)
If a suspension occurs because of the reckless behavior described in §51.241(a)(2) of this chapter, then services must not continue during the appeal process.

An applicant/individual may appeal a DADS action, including suspensions, reductions in service, service denials or case closures. An applicant/individual may request an appeal to the case manager either orally or in writing within 90 days from the date of the notification. The individual is no longer required to request continued services. The case manager must continue services if the individual files the appeal before the effective date of the case action unless services cannot continue due to required suspensions or program termination due to loss of Medicaid. The case manager must continue to follow policy in Section 5500, Loss of Medicaid, for terminations due to loss of Medicaid. If an individual chooses not to receive services while a fair hearing is pending, he must provide a clear, written statement requesting services stop. The individual will continue to have up to 90 days from the date of the notification to appeal the decision.

The case manager must explain the applicant's/individual's right to appeal by reviewing Form 2417, Rights and Responsibilities of Families/Primary Caregivers/Independent Individual, along with the right for others to represent the applicant/individual, including legal counsel at the initial assessment and at each annual reassessment. The applicant/individual must sign a copy of the Form 2417 for the case file. The case manager must provide a copy of Form 2417 to the applicant/individual. The case manager may inform the applicant/individual to keep the copy in the in-home record.

9610  Appeals Process

Revision 12-1; Effective May 1, 2012

Upon notification of a request for a fair hearing, the case manager must initiate procedures to generate the fair hearings process detailed in Section 9611, Case Manager and Designated Data Entry Representative Procedures, Section 9611.1, Procedures for Loss of Medicaid, and Section 9611.2, Procedures for Medical Necessity (MN) Denials, through the Texas Integrated Eligibility Redesign System (TIERS). Each region must designate a data entry representative who is responsible for entering all fair hearings information into the TIERS Fair Hearings and Appeals System. The case manager must work with the regional representative to ensure the applicant's/individual's request is submitted timely.

9611  Case Manager and Designated Data Entry Representative Procedures

Revision 13-3; Effective August 1, 2013

Upon receipt of the fair hearings request from an applicant/individual, the case manager completes Form 4800-D, DADS Fair Hearing Request Summary. The case manager will send the form to the regional data entry representative and the supervisor within three days of the request for a hearing. The three-day time frame allows the data entry representative two days to enter the information into the Texas Integrated Eligibility Redesign System (TIERS).

When the case manager completes Form 4800-D, all questions in Section 3, “Appellant Details - Programs,” must be answered. In Subsection D, “Summary of Agency Action and Citation,” the case manager must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

The case manager must indicate the Individual Plan of Care (IPC) 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 fair hearing so the hearings officer is aware of when the IPC year ends when rendering a decision.  

The case manager must indicate the names and titles, addresses and telephone numbers of all persons or their designees who will attend the hearing on Form 4800-D. Depending on the issue being appealed, the following persons must attend:

  • Texas Medicaid & Healthcare Partnership (TMHP) staff for medical necessity (MN) denials;
  • Centralized Representation Unit (CRU) staff for financial denials;
  • the case manager or designee for all case decisions; and/or
  • the utilization review nurse, if applicable to the appeal action.

Within two days of receipt of Form 4800-D, the data entry representative must enter the information into the TIERS Fair Hearings and Appeals System. The TIERS Fair Hearings and Appeals System will assign an appeal identification (ID) number when all the information is data entered. The data entry representative must document the appeal ID number as directed by the form instructions.

With the exception of Section 9611.1, Procedures for Loss of Medicaid, Section 9611.2, Procedures for Medical Necessity (MN) Denials, and Section 9611.3, Procedures for Utilization Review Findings, the case manager is the agency representative and the case manager's supervisor is the agency representative supervisor. These fields are used to send out the notification of the fair hearings schedule.

9611.1  Procedures for Loss of Medicaid

Revision 14-1; Effective February 3, 2014

The Centralized Representation Unit (CRU) represents the Health and Human Services Commission (HHSC) in all Medicaid hearings regarding Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works determinations. The CRU replaces the MEPD and Texas Works specialist in specific steps related to denial of Medicaid applications and ongoing cases. The CRU:

  • represents HHSC Office of Eligibility Services (OES) in fair hearings;
  • completes and implements all Medicaid case actions based on fair hearings decisions; and
  • coordinates actions required with regional MEPD or Texas Works staff and DADS staff.

The case manager must coordinate all appeals involving loss of MDCP eligibility due to loss of Medicaid with the CRU.

The following procedures must be used by the case manager to coordinate appeal actions with the CRU in cases for which MEPD or Texas Works staff determine Medicaid eligibility. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

The case manager completes Form 4800-D, DADS Fair Hearing Request Summary, following policy in Section 9611, Case Manager and Designated Data Entry Representative Procedures. The case manager must determine if the appealed action is:

  • a non-Medicaid program denial (excludes MDCP denials based on Medicaid denials); or
  • a program denial based on Medicaid financial eligibility (MDCP denials based on a Medicaid denial action).

If the appealed action is related to a non-Medicaid program denial, the case manager completes Form 4800-D and enters his name as the agency representative. In the Other Participants field, DADS staff enter the CRU supervisor and CRU administrative assistant. The CRU supervisor and assistant name must be entered by using the Model Office Resources (MOR) Search function. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System (TIERS) and CRU staff will receive the notice of the appeal.

If the appealed action is a program denial based on Medicaid financial eligibility, the case manager completes Form 4800-D. In Section 6 of Form 4800-D, DADS staff must select YES to the question: "Are you an OES Texas Works or MEPD employee?" (DADS staff are responding to this question on behalf of the CRU.) On the Agency Representative page, select Yes in the dropdown. Failure to answer Yes to this item will result in the CRU not being notified of the hearing. DADS staff continue completing Form 4800-D and enter the CRU supervisor as the agency representative. DADS staff must enter this information through the MOR Search function for the CRU to receive the hearing information. DADS staff must list the case manager's name and title in the Other Participants section. The case manager does not enter the name of the local MEPD or Texas Works specialist on Form 4800-D for MEPD financial appeals. The DADS staff must include his title, such as DADS case manager or DADS supervisor. Enter the DADS staff email address. Also include the CRU administrative assistant in Other Participants. The CRU administrative assistant's information must be entered through the MOR Search function.

When Form 4800-D is sent to the designated data entry representative, DADS staff send an email notification to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which is monitored by CRU staff and can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings, regarding the request for an appeal. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID (include Appeal ID number). In an attachment to the email, DADS staff must include a copy of the DADS notification form sent to the applicant or individual.

The body of the email must include the:

  • applicant's/individual's name;
  • Medicaid number (if available);
  • name of the waiver program; and
  • specific information requesting the Medicaid financial case remain active/open during the appeal, if the applicant/individual appealed in a timely manner. For example, the financial case or application may need to remain open pending an appeal decision regarding medical or functional eligibility. DADS staff must notify the CRU to keep the Medicaid case open pending the fair hearings decision.

Upon receipt of notification of an appeal, the CRU requests the Medicaid evidence packet from the local MEPD or Texas Works specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent HHSC at the hearing, if required, and takes steps to ensure the appropriate Medicaid financial case action is taken once a hearings officer's decision is rendered.

When an MDCP denial hearings decision is rendered by the hearings officer, DADS staff (staff name entered as agency representative) will be notified via email of the decision by the hearings officer. Based on the hearings decision, the case manager determines the appropriate action for MDCP services according to specific time frames. The case manager may need to coordinate effective dates of reinstatement with the CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. DADS staff reports the implementation of the hearings decision through TIERS on Form 4807-D, DADS Action Taken on Hearing Decision, according to current procedures.

For individuals with ME-Waivers, the local MEPD specialist will continue to notify DADS staff if an appeal is filed by MEPD regarding a financial eligibility decision, and refer the MEPD case to the CRU to handle during the appeal process. Once the appeal decision regarding the Medicaid eligibility is rendered by the hearings officer, the CRU will notify DADS staff via email of the hearings decision, including decisions that are sustained, reversed or withdrawn. Based on the hearings decision, the case manager determines the appropriate action for MDCP. The email sent by the CRU will include:

  • the applicant's/individual's name;
  • Medicaid number;
  • a copy of the hearings decision; and
  • the effective or denial date of Medicaid eligibility.

DADS staff must not put an applicant/individual back on the MDCP interest list while a Medicaid denial is in the appeal process. The case manager must take appropriate action to certify or deny the case, or resume services once the Medicaid hearings decision is rendered. The individual may choose to be added back to the MDCP interest list once the case manager denies MDCP.

9611.2  Procedures for Medical Necessity (MN) Denials

Revision 12-1; Effective May 1, 2012

Texas Medicaid & Healthcare Partnership (TMHP) is the designated agency representative for all fair hearings resulting from a denied MN. A TMHP staff member will be designated as the contact person and will handle the assignment for fair hearings.

The case manager completes Form 4800-D, Fair Hearing Request Summary, and enters the TMHP contact as the Agency Representative. The case manager must check with the supervisor for the name of the current TMHP representative. DADS staff must enter this information through the Model Office Resources (MOR) Search function. No other information is required for Section 6, Agency Representative or Section 7, Agency Representative Supervisor, as these will be automatically populated. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System and TMHP staff will receive the notice of the appeal. The case manager's name, title and email address and the case manager's supervisor's information are entered in Section 8, Other Participants, along with any other participants.

9611.3  Procedures for Utilization Review Findings

Revision 13-2; Effective May 1, 2013

When an applicant/individual appeals an action as a result of utilization review (UR) findings, the case manager must inform the UR nurse who completed the review and UR regional manager via email that a fair hearing has been requested as a result of the UR findings.

On Form 4800-D, DADS Fair Hearing Request Summary, the case manager will list the UR nurse in Section 6, Agency Representative, and UR regional manager in Section 7, Agency Representative Supervisor.  The case manager will be listed in Section 8, Other Participants. The case manager must confirm the correct UR nurse and UR regional manager to list on the form. The case manager includes the UR nurse whose name is located in Section A of the utilization review tool. The case manager identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The UR nurse and UR regional manager will develop the fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or individual. The evidence packet will include a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the evidence packet in the Texas Integrated Eligibility Redesign System and forward a copy of the fair hearing evidence packet to the applicant/individual.

The evidence packet submitted by the case manager will include the applicable notification form. If available, the case manager includes the signed notification form returned by the applicant or individual. The case manager does not include any other documentation in the evidence packet. The designated Data Entry Representative (DER) will be responsible for uploading the case manager’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system.

The UR nurse, UR regional manager (optional) and case manager will participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony regarding the case action.

9612  Sending Additional Information

Revision 14-1; Effective February 3, 2014

When an applicant or individual requests a fair hearing, the burden of proof to uphold the DADS decision rests with DADS. The fair hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is, therefore, crucial that staff complete and organize all fair hearing packets in order to support DADS decision.

If Form 4800-D, DADS Fair Hearing Request Summary, has already been submitted into the Texas Integrated Eligibility Redesign System (TIERS), and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for the fair hearing, the case manager must use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all documentation to the fair hearings officer. The appeal identification (ID) number assigned by the Texas Integrated Eligibility Redesign System (TIERS) must be written on Form H4800-A. The fair hearings officer's contact information is located on Form H4803, Notice of Hearing.

The case manager will review the request to determine the appropriate documentation to submit to the fair hearings officer as the fair hearings packet. Examples of additional information and who is responsible for submitting that information to the fair hearings officer and appellant include, but are not exclusively limited to:

  • the case manager or designee:
    • Texas Administrative Code or policy handbook references, including Memoranda, related to the case action;
    • summary of events;
    • a copy of any individual plan of care (IPC) or other official documentation forms, including form instructions;
    • a copy of the MDCP explanation of medical necessity (MN) and resource utilization group (RUG) value calculation found in Appendix XX, Medical Necessity Determination and Resource Utilization Group Value Calculation Explanation, if MN determination or RUG value change or calculation is in question;
    • other documentation supportive of the decision, such as records of telephone calls, visit summaries, etc.;
    • any relevant utilization review findings; and
    • a signed copy of the denial notification form (if available, use the signed form returned by the applicant/individual when the appeal was filed).
  • Centralized Representation Unit (CRU) staff:
    • documentation supportive of the financial decision, including official documentation forms, telephone calls, etc.; and
    • a copy of the original signed denial form returned by the member, if available (if unavailable, send unsigned copy).
  • Texas Medicaid & Healthcare Partnership (TMHP) staff:
    • a copy of the Medical Necessity/Level of Care (MN/LOC) Assessment; and
    • other documentation supporting the decision.

The case manager must identify the information presented to the fair hearings officer as "submit as evidence" specifying policy or rule citation. The fair hearings officer may not be familiar with policy and may not have time or resources to read through lengthy documentation. The designated data entry representative must upload in TIERS all supporting documentation no later than 10 calendar days prior to the fair hearing date.

Regional Responsibilities

TIERS generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The case manager and the case manager's supervisor receive a copy of Form H4800 and the letter identifying the fair hearings officer assigned, and the time and location of the fair hearing. The staff or designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent DADS during the fair hearings process.

Each entity involved in the fair hearing is responsible for preparing its fair hearings packet and forwarding it to both the fair hearings officer identified on Form H4800 and the appellant no later than 10 calendar days prior to the hearing date. All documentation must be neatly and logically organized, and all pages numbered.

Scanning the Evidence

All fair hearings packets must be scanned into the TIERS Fair Hearings and Appeals System. The designated data entry representative uses Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the fair hearings officer. The appeal ID number assigned by TIERS must be written on the top of Form H4800-A.

At least 12 working days before the fair hearings date, the case manager:

  • goes to the multi-function office Workcenter and scans in the documentation;
  • saves the document by either allowing the default document name or entering a name;
  • retrieves the scanned documents and attaches it to an email; and
  • sends the document to the designated data entry representative.

No later than 10 calendar days prior to the fair hearing date, the designated data entry representative:

  • saves the attachment to the appropriate network drive, as assigned by regional management;
  • without launching TIERS, goes into the TIERS portal and selects the Appeals tab;
  • ensures the appeal has been entered in TIERS and a fair hearings officer has been assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information;
  • selects Hearing Evidence Packets Upload and enters the Appeal ID;
  • selects Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the fair hearings packet);
  • selects Validate;
  • checks details to ensure the right person has been selected;
  • browses for the document; and
  • selects Upload.

The data entry representative then sends the fair hearings officer an email with Form H4800-A attached. The data entry representative must enter the appeal ID in the subject line. The email must also inform the fair hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded in TIERS. The case manager and data entry representative must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

When Form H4800-A is completed informing the fair hearings officer of address changes, participant updates and withdrawal forms, the designated data entry representative must check TIERS for the fair hearings officer assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information. When sending the information, the data entry representative sends Form H4800-A directly to the fair hearings officer’s email address. The data entry representative must enter the appeal ID in the subject line.

Presentation of the Evidence

Documentation contained in the fair hearings packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence, and summarize the contents of the packet.

Example: I want to offer the following packet as evidence in the appeal filed on the behalf of (appellant's name). Pages 1-10 contain information relating to the completion of Form 2410, Medical-Social Assessment and Individual Plan of Care. Pages 11-15 contain policy from the Case Manager Medically Dependent Children Program Handbook, which relate directly to the issue in question. Pages 16-17 contain documents signed by the appellant related to rights and responsibilities. Page 18 contains Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, which was mailed to the appellant on (date).

The fair hearings officer may ask the appellant if he received the fair hearings packet. If not, the fair hearings officer may attempt to determine why. If no effort was made to send a copy of the fair hearings packet to the appellant, the packet may not be admitted, and the appropriate agency representative will have to read information into the record in order to have it considered as evidence.

The fair hearings officer may ask for objections and allow all admissible documents into evidence. Any documents admitted by the fair hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case has been clearly presented. If any documents are not admitted, the fair hearings officer will explain the reasons for excluding the material.

9613  Request to Withdraw an Appeal

Revision 13-3; Effective August 1, 2013

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office.  An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer.  The case manager should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer.  If the appellant or appellant representative contacts the case manager regarding the withdrawal, the case manager must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal.  If the appellant or appellant representative sends a written request to withdraw to the case manager, the case manager must forward this written request to the hearings office.  A fair hearing will not be dismissed based on a DADS decision to change the adverse action.  All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify DADS by phone or email and open the conference line to inform participants of the cancellation.  If the appellant or appellant representative requests to withdraw his 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 (TIERS) and a written notice will be sent to participants informing them of the fair hearing cancellation.

9614  Appeals and Continuation of Services

Revision 14-1; Effective February 3, 2014

Service Reductions or Service Terminations During an Individual Plan of Care (IPC) Period

When the reduction or termination of specific services is taken during the IPC period, the case manager must include comments on Form 2065-B, Notification of Waiver Services, explaining the reason for the service reduction or termination. The case manager must continue services at the current level when an individual files an appeal before the effective date of the reduction or termination until the hearings officer’s decision is rendered.

Example: During the IPC period, the case manager determines Flexible Family Support Services (FFSS) must be reduced from 20 hours a week to 10 hours a week due to a change in the primary caregiver’s work schedule. The case manager sends Form 2065-B to the individual and Home and Community Support Services Agency (HCSSA) as notification of the reduction in FFSS. The individual appeals before the effective date of the reduction. The case manager authorizes FFSS at 20 hours a week until the hearings officer’s decision is rendered.

IPC Changes or Service Terminations at Annual Reassessment

When an individual remains eligible at the annual reassessment, but some of the services in the new IPC are reduced or terminated, the case manager must continue services that were reduced or terminated at the current level if the individual files an appeal before the effective date of the reduction or service termination until the hearings officer’s decision is rendered. The case manager must document the individual’s disagreement in the case narrative. The individual can request new or increased services other than those being appealed while the fair hearing is pending. The case manager processes the new requests following established procedures.

Example: At the annual reassessment, the individual continues to be eligible for MDCP, but Respite hours are reduced from 40 to 20 hours a week. The individual signs Form 2410, Medical-Social Assessment and Individual Plan of Care, but does not agree with the reduction in Respite hours. The case manager sends Form 2065-B and Form 2410 to the individual and MDCP providers. The individual appeals before the effective date of the reduction. The case manager authorizes Respite at 40 hours per week pending the hearings officer’s decision. The individual later requests an adaptive aid while the appeal is pending and the case manager processes the request following established policy.

Program Terminations

When an individual is terminated from the program, such as at the annual reassessment, the case manager must continue services at the current level if the individual files an appeal before the effective date of the termination until the hearings officer’s decision is rendered. The case manager must not authorize any new or increased services or items until the hearings officer’s decision is rendered. If the individual requests to add or increase services, the case manager must complete and send Form 2065-B to notify the individual that the request for additional services or items pending the hearings officer’s decision cannot be processed. The case manager explains that new or increased services or items may be reviewed for authorization once the hearings officer’s decision is rendered.

Example: At the annual reassessment the individual has been denied Medical Necessity (MN) and the case manager sends Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to the individual and the MDCP provider as notification of the termination of services. The individual appeals by the effective date of the program termination. The case manager authorizes services at the same level as authorized on the current IPC pending the hearings officer’s decision. The individual later requests an adaptive aid that is not on the current IPC. The case manager completes and sends Form 2065-B to notify the individual the request will not be processed pending the hearings officer’s decision.

When an individual determined ineligible at the annual reassessment files an appeal before the effective date of the termination and the hearings officer’s decision will not be made until after the IPC expires, the case manager must enter the current level of services in the Service Authorization System (SAS) for a full IPC year, effective the first day following the end of the current IPC period. The IPC entered into SAS must reflect services authorized at the same level of the current IPC and must not increase, decrease, add or terminate any service. Exception: The case manager does not include one-time items or services from the current IPC, such as adaptive aids or minor home modifications. The case manager must not use the new annual reassessment IPC for services continued pending the outcome of the fair hearing.

For an individual denied MN at the annual reassessment, the case manager will not create an approved MN record and will leave the denied MN in the MN record. The case manager must manually enter a Level of Services (LOS) and Diagnosis record from the previous Medical Necessity and Level of Care (MN/LOC) Assessment for the new IPC period. This ensures the MDCP provider can be paid for services delivered after the expiration date of the current IPC and until the outcome of the fair hearing.

Provider Notifications

Within three working days after an individual appeals a reduction or termination of a service during an IPC period and services will continue, the case manager must notify authorized MDCP providers using Form 2067, Case Information, to provide services at the current IPC level until the hearings officer’s decision is rendered.

Within three working days after an individual appeals a termination of program eligibility and services will continue, such as at the annual reassessment, the case manager must notify authorized MDCP providers using Form 2067 to provide services at the current IPC level until the hearings officer’s decision is rendered. The case manager must also state on Form 2067 that IPC change requests received while the fair hearing is pending will not be processed. If an MDCP provider submits a change request while a fair hearing is pending, the case manager returns the request to the MDCP provider with Form 2067 stating a fair hearing regarding the individual’s eligibility is pending. The case manager completes and sends Form 2065-B to the individual to notify the individual the request will not be processed pending the fair hearing officer’s decision.

When an individual submits a written statement requesting services to stop, the case manager must send Form 2067 to the MDCP provider with an effective date to stop service delivery. The case manager does not send another Form 2065-B or Form 2065-C to the individual or MDCP provider. Refer to Section 9621, Fair Hearing Decision, for information related to effective dates.

9620  Fair Hearing

Revision 12-1; Effective May 1, 2012

A fair hearing is an informal proceeding held before an impartial HHSC fair hearings officer in which an applicant/individual appeals a DADS action. Unless the DADS action is based on federal or state law, an MDCP applicant/individual has a right to a fair hearing for:

  • an action to reduce, suspend, terminate or deny eligibility;
  • the denial of a prior authorization request; and
  • the failure to reach a service authorization decision within the time period specified by federal law.

The applicant/individual has the right to appeal an action within 90 days from the date on the notice of DADS action.

At the fair hearings officer's discretion, the fair hearing may be conducted by telephone or in person.

9621  Fair Hearing Decision

Revision 12-1; Effective May 1, 2012

After the fair hearing is held, the fair hearings officer will send a decision letter to the MDCP applicant/individual and send copies to the case manager and the unit supervisor. Notification is sent via email to those participants with an email address. Decisions to dismiss and withdraw the fair hearings request can be viewed in the History Correspondence tab of the TIERS Fair Hearings and Appeals System. The fair hearings decision can also be viewed under the Decision tab. Within 10 days of receipt of the fair hearings officer's decision, the case manager must take appropriate case action to implement the fair hearings officer's decision. The case manager must place a copy of the decision in the case file and ensure a copy of Form 4807-D, DADS Action Taken on Hearing Decision, is entered into the Fair Hearings and Appeals System. Follow procedures in Section 9611.1, Procedures for Loss of Medicaid, to coordinate hearing decisions with Medicaid for the Elderly and People with Disabilities and Texas Works staff.

If the appellant applicant/individual is not satisfied with the fair hearings officer's decision, the applicant/individual may request the fair hearings officer conduct an administrative review. Administrative review of any fair hearings officer's decision provided in the fair hearings rules must be initiated by the appellant applicant/individual. DADS staff may disagree with the hearings officer's decision; however, in most cases the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by DADS staff to management for further review. See Section 9622, Fair Hearing Exception, for procedures to request program management review of a hearings officer's decision.

9621.1  Action Taken on Fair Hearing Decision

Revision 12-1; Effective May 1, 2012

Within 10 days of receipt of the fair hearings officer's decision, the case manager must take appropriate case action to implement the fair hearings officer's decision. The case manager must verify the fair hearings officer's decision by obtaining a copy of the decision that is to be filed in the case file.

9621.2  Procedures for Sustained Decisions

Revision 14-1; Effective February 3, 2014

When the fair hearings officer's decision sustains the denial of MDCP services, the case manager must:

  • notify the applicant/individual via telephone (or letter, if he does not have a telephone) of the fair hearings officer's decision and the termination effective date of MDCP services;
  • notify all providers via Form 2067, Case Information, to deliver services to the individual through the MDCP termination effective date if services were continued during the appeal process;
  • ensure MDCP (service group 18) services are terminated in the Service Authorization System (SAS) and consult the SAS help file for record terminations; and
  • coordinate the fair hearings officer's decision and the termination effective date of MDCP services for the individual whose Medicaid eligibility was determined by Medicaid for the Elderly and People with Disabilities (MEPD) staff.

When the fair hearings officer's decision sustains the reduction or termination of specific services during the individual plan of care (IPC) period or at the annual reassessment when the individual remains eligible for MDCP, the case manager must:

  • notify the providers via Form 2067 to provide services as directed in the decision;
  • assure the IPC is registered in SAS with the appropriate services and effective date; and
  • authorize the reduced service or terminate the specific services for the remainder of the IPC period.

The case manager must not complete or send an additional Form 2065-B, Notification of Waiver Services, or Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services, to an applicant/individual confirming a fair hearings officer's decision to sustain a DADS action.

The fair hearings officer will send the applicant a copy of the decision sustaining a denial of MDCP eligibility. The case manager is not required to send by any additional notification.

Sustained Decisions – Effective Dates

When services are terminated at the annual reassessment due to the individual not meeting eligibility criteria, including medical necessity, and services are continued until the appeal decision is known, the MDCP termination date is:

  • 30 days from the fair hearings officer's decision date, the date the order is signed as recorded on the decision letter, when the fair hearings officer's decision date is:
    • less than 30 days before the end of the IPC in effect when the appeal was filed; or
    • after the end of the IPC in effect when the appeal was filed, and a new IPC was developed to continue services past the IPC end date until the appeal decision was made; or
  • at the end of the IPC in effect at the time the appeal was filed in cases where the fair hearings officer's decision is 30 days or more before the end of the IPC in effect when the appeal was filed.

When services are denied or reduced during the IPC period, the MDCP termination or reduction in service effective date is the effective date of the fair hearings officer's decision as recorded on the decision letter.

When an applicant is denied MDCP services, the effective date is the date of the fair hearings officer's decision as recorded on the decision letter.

9621.3  Procedures for Reversed Decisions

Revision 14-1; Effective February 3, 2014

When the fair hearings officer's decision reverses DADS case action on an MDCP applicant/individual, or the reduction in services during the individual plan of care (IPC) period, the fair hearings officer sends Form H4807, Action Taken on Hearing Decision. The fair hearings officer specifies the corrective action to be taken and a 10-day time frame for completing the action. The case manager actions required by the fair hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals System within the 10-day time frame.

The case manager must complete and send Form 4807-D, DADS Action Taken on Hearing Decision, recording case actions taken, to the supervisor for review and signature. The supervisor will forward the form to the designated data entry representative for data entry. DADS staff have 10 days from the date DADS received the fair hearings officer's decision to enter the information into the TIERS Fair Hearings and Appeals System. The 10-day time frame includes at least two days for the data entry representative to enter the information into the system. The case manager and supervisor must coordinate form completion efforts to have the information available for the data entry representative to ensure DADS meets the 10-day time frame.

If the action cannot be taken by the time frame designated by the hearings officer, Section C, “Implementation Delays,” on Form 4807-D is completed and sent to the supervisor and data entry representative within the 10-day time frame providing a reason for the delay. Acceptable reasons are listed on the form and the begin delay date and the end delay date must be included.

If the hearings officer reverses the decision to reduce or terminate a service, the case manager continues authorization of the higher level of services. The case manager must provide a copy of the correct authorization to the MDCP provider.

If the hearings officer reverses the decision to terminate program eligibility, the case manager must:

  • notify providers via Form 2067, Case Information, as appropriate, to provide services to MDCP individuals as directed in the decision;
  • complete annual reassessment activities using the previously developed annual reassessment taking into account previously continued services (the individual’s total cost of services must remain at or under the IPC cost limit);
  • send Form 2065-B, Notification of Waiver Services, to the MDCP:
    • individual who was denied at reassessment and all providers to notify them the denial decision was reversed and the individual is eligible for MDCP services for the new IPC period; and
    • applicant who was denied at application and all providers to notify them of eligibility for MDCP services;
  • include in the comments section of Form 2065-B the following statement, “The hearings officer has overturned the termination decision and you have been determined eligible for services effective (IPC begin date).”
    • assure the IPC is registered or updated in the Service Authorization System (SAS) with the correct services and effective dates at the same time Form 2065-B is signed:
  • provide the accurate IPC to the individual and providers; and
  • coordinate with Medicaid for the Elderly and People with Disabilities staff, as appropriate, to continue Medicaid eligibility.

If the SAS data entry cannot be completed at the same time Form 2065-B is signed, the delay must be documented in the case file.

Reversed Decisions – Effective Dates

The fair hearings officer's decision date recorded on the decision letter or Form H4807 is considered the eligibility or effective date of MDCP services for all reversed decisions involving services denied:

  • at the annual reassessment due to the individual not meeting eligibility criteria, regardless if services continued during the appeal process or not;
  • or reduced during the IPC period; or
  • at the initial enrollment.

Refer to Section 9621.4, Procedures When Medical Necessity (MN) Denied is Overturned, for procedures regarding medical necessity denial.

9621.4  Procedures When Denied Medical Necessity (MN) is Overturned

Revision 12-1; Effective May 1, 2012

Upon receipt of an email from the fair hearings officer notifying Texas Medicaid & Healthcare Partnership (TMHP) of an overturned medical necessity (MN) decision, the TMHP representative will:

  • forward the email to the case manager and supervisor the day it is received to notify them the MN decision was overturned;
  • change (reverse) the assessment MN status to approve via TMHP's web-based portal;
  • notify the case manager and supervisor by email of the MN decision reversal in the portal within three days of receipt of the decision (excluding state holidays); and
  • email copies of all decisions (upheld, reversed, withdrawn and dismissed) from the fair hearings officer to the case manager and supervisor.

The case manager must complete Form 4800-D, DADS Fair Hearing Request Summary, to be entered into the Texas Integrated Eligibility Redesign System (TIERS). The case manager's and supervisor's name, title and email address must be entered in the Other Participants section of Form 4800-D and entered appropriately into TIERS. If there is no name, title or email address in TIERS, TMHP will not be held responsible for forwarding information to the case manager and supervisor. See Form 4800-D instructions for additional instructions to correctly enter all information on the form and in TIERS.

Upon receipt of the second email from TMHP, the case manager must implement the overturned decision and complete Form 4807-D, DADS Action Taken on Hearing Decision, and submit to the data entry representative for data entry into TIERS.

The entry into TIERS must be completed within seven days from the receipt of the second email from TMHP. (This is 10 days from the fair hearings officer sending the decision to TMHP.) The day TMHP receives the decision is considered "Day 0" and TMHP has three days to reverse the MN assessment in the portal and notify DADS. When the notification is received, the case manager must complete and send Form H4807-D to the data entry representative, allowing two days for data entry.

Reversed Decisions – Effective Date

The effective date for reversals related to MN denials is the date TMHP received the MN/LOC Assessment.

9621.5  Procedures When a New Assessment is Required by a Fair Hearing Decision

Revision 13-3; Effective August 1, 2013

When the fair hearings officer’s final decision orders completion of a new Medical Necessity and Level of Care Assessment (MN/LOC), the hearing is closed as a result of this ruling.  The case manager must notify the individual of the results of the new assessment on Form 2065-B, Notification of Waiver Services.  The individual may appeal the results of the new assessment.  If the individual chooses to appeal, the case manager must indicate in Section 3.D. “Summary of Agency Action and Citation,” of Form 4800-D, DADS Fair Hearing Request Summary, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision.  If the individual requests an appeal of the new assessment and services are continued, DADS continues services until the second fair hearing decision is implemented.

Example: An individual is denied medical necessity (MN) at an annual reassessment and requests a fair hearing and services are continued.  The case manager would continue services at the level the individual was receiving prior to the MN denial.  The hearings officer then orders a new MN/LOC assessment which results in another MN denial.  The case manager sends a notice to the individual informing him of the MN denial.  The individual then requests another fair hearing and services are continued pending the second fair hearing decision.  The case manager would continue 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 level resulting in a reduction in services and the individual requests a fair hearing, the case manager would continue services at the same level services were continued prior to the first fair hearing.

9622  Fair Hearing Exception

Revision 12-1; Effective May 1, 2012

To help ensure that HHSC policy is consistently applied by DADS staff and fair hearings officers, the fair hearings exception process may be used when a fair hearings decision seems to be in conflict with DADS policy.

9622.1  Fair Hearing Exception Process

Revision 12-1; Effective May 1, 2012

When a fair hearing decision is rendered, staff must implement the decision of the fair hearings officer within the applicable time frames, including the restoration of any benefits or services.

If the case manager disagrees with the fair hearings decision, the case manager discusses the decision and all the applicable policy with the supervisor. If the supervisor agrees with the case manager, then the supervisor submits a fair hearing exception request, using Form 1590, Request for a Fair Hearing Exception, outlining the details of the hearing decision and all the relevant rules/policy citations from the rules and handbook, to the regional director (RD).

The documentation must include:

  • case actions taken by the case manager that lead to the appeal;
  • a summary of the fair hearings officer's decision;
  • points of disagreement; and
  • pertinent policy citations.

The RD reviews the information and if not in agreement with the request, indicates that decision and sends an appropriate response back to staff. If the RD is in agreement with the request for the exception, the RD forwards Form 1590 to the Community Services Policy (CSP) Unit manager. The CSP Unit manager must receive the form by the fifth calendar day following the date of the hearing decision. A copy of the form is kept in the regional files, not in the case record.

9622.2  Community Services Policy Staff Actions

Revision 13-2; Effective May 1, 2013

Upon reviewing the region's exception request, the Community Services Policy (CSP) Unit manager will decide whether to forward the exception request for consideration by the Health and Human Services Commission (HHSC). If the CSP unit manager (or designee):

  • concurs with the regional assertion that policy was misapplied, the form is forwarded to the Fair and Fraud Hearings Section.
  • determines a clear error of law or fact was made by the hearings officer, he/she requests that HHSC review the case action and, if they are in agreement, issue a revised hearing decision.
  • does not concur with the regional request, does not forward the request to HHSC.

The region will be notified of the decision whether the request was or was not forwarded to HHSC. Even if an exception request is being filed, the hearings officer's decision must be implemented within the required time frames.

If the exception request was sent to HHSC, the case manager must send Form 1015 or Form 1015-S, Fair Hearing Exception Letter, to notify the applicant/individual that DADS sent an exception request regarding a fair hearing decision to HHSC.  The case manager must place the letter and exception request in the outgoing mail by the close of the next business day following receipt of the notification from the CSP unit manager.  A copy of the letter and exception request must be filed in the case file.

The fair hearings manager conducts a preliminary review of the decision w with input from relevant stakeholders. If the fair hearings manager agrees with the exception request and does not uphold the hearing decision, a response is sent back to the CSP Unit manager who forwards the information to the regional director (RD), along with any additional instruction regarding necessary case actions.

If the fair hearings manager upholds the hearing decision and if the CSP Unit manager and policy staff still disagree with the hearing decision, the information is sent to the DADS attorney for review and additional rule and policy citation. If the DADS attorney agrees to uphold the hearing decision, the information is sent back to the RD noting the rule and policy citations. If the DADS attorney does not agree to uphold the hearing decision and determines that a correct decision was made by DADS staff, then the CSP Unit manager prepares a response containing the information from the DADS attorney regarding the policy. This final decision memorandum is signed and sent to the:

  • DADS attorney;
  • RD;
  • fair hearings administrator; and
  • fair hearings manager.

The exception process ensures that policy has been interpreted correctly, provides feedback to regional staff and allows for communication with the Fair Hearings Division. While the outcome of the fair hearing may not change, this process provides guidance for the fair hearings officer and regional staff with correct policy and procedures for future decisions.