Medicaid appeals in Texas: hearing deadline and keeping benefits

Medicaid (Texas Medicaid (STAR, STAR+PLUS, STAR Kids, STAR Health)) denials in Texas

Medicaid agency

Texas Health and Human Services Commission (HHSC)

Who holds the hearing

HHSC Appeals Division, Fair and Fraud Hearings

Hearing deadline

90 days

The effective date of the action or the date of the notice of adverse action, whichever is later

If you are late

You can still ask after the deadline. The hearings officer decides whether you had good cause, meaning something out of your control made you miss the deadline.

How to ask for a hearing

• Phone: Call 2-1-1 (most appeal requests can be made by phone)
• Mail: Write to the address on your Notice of Case Action
• In person: Visit a local HHSC office
• Phone: If the issue is about your health plan (MCO) services, contact your MCO service coordinator

2-1-1

What to include

Say that you want to appeal and which action you disagree with. A request can be oral or written. If you have documents you want the hearings officer to see, send them to the hearings officer before the hearing.

Source: the address and fax are on the Notice of Hearing

Keeping your benefits during the appeal

If you already get benefits, they continue until the hearing decision if you ask for a fair hearing within 13 days of the adverse action notice (a mailed request postmarked within the 13 days counts). This is the rule in the Texas Works Handbook, which covers Medicaid for children, families and pregnant women. If the hearing upholds the action, HHSC may ask you to pay back the cost of continued benefits. For an appeal to a Medicaid health plan (MCO), the federal 10-day rule for plan appeals applies.

Law: HHSC Texas Works Handbook B-1051; 42 CFR 431.230; 1 Tex. Admin. Code 357.3, 357.7, 357.17; HHSC Fair and Fraud Hearings Handbook 1420, 1522

When the hearing is held

Most hearings are by phone. You get a Notice of Hearing at least 14 calendar days before the hearing. The hearings officer must issue a decision within 90 days of your request (60 days for SNAP).

Law: 1 Tex. Admin. Code 357.15(a); HHSC Fair and Fraud Hearings Handbook 1510; 1 Tex. Admin. Code 357.3, 357.7, 357.17; HHSC Fair and Fraud Hearings Handbook 1420, 1522

Faster (expedited) hearing

You, your representative or your provider can ask for an expedited hearing if waiting could seriously jeopardize your life, physical or mental health, or ability to attain, maintain or regain maximum function. If granted, the decision is due within 5 working days after the hearings officer gets the request (Medicaid), or within 3 working days after the hearings officer gets the agency's evidence (managed care), if you agree to shorter notice and no more information is needed.

Law: 1 Tex. Admin. Code 357.3, 357.7, 357.17; HHSC Fair and Fraud Hearings Handbook 1420, 1522

Ombudsman

Texas HHS Office of the Ombudsman, Managed Care Help · 1-866-566-8989

Medicaid health plan (managed care) in Texas

Appeal to the plan first

Appeal to your Medicaid health plan (MCO) first. If the MCO says no, you have 120 days from the MCO's final decision to ask for a State Fair Hearing, and you can also ask for an External Medical Review before the hearing.

Then a state hearing

120 days

The date of the MCO's final determination on your internal appeal

Optional outside medical review

After the MCO denies your appeal of a reduction or denial of services based on medical necessity, you can ask for an External Medical Review by an independent reviewer HHSC contracts with. It happens after the MCO appeal and before the fair hearing, and you must ask for it. The reviewer's decision sets the minimum level of services you must receive.

Late requests

Requests after 120 days are reviewed for good cause.

Law: Tex. Gov. Code 532.0404; HHSC Fair and Fraud Hearings Handbook 1420; HHSC Fair and Fraud Hearings Handbook 42 CFR 438.402, 438.408

Write my appeal: free letters

Letter: Medicaid fair hearing request