1. (a) Purpose. The Health and Human Services Commission (HHSC) is required by state law to promulgate uniform fair hearing rules for all Medicaid-funded services.

   1. (1) An opportunity for a fair hearing is required by federal law and regulation:

      1. (A) in any Medicaid case for an individual whose claim for services is denied or not acted upon promptly;
      2. (B) when an operating agency or its designee takes action to suspend, terminate, or reduce services, including a denial of a prior authorization request for Medicaid-covered services;

      3. (C) when a Managed Care Organization (MCO) takes an action, as defined in §357.3 of this chapter (relating to Definitions); following an MCO action an MCO enrollee may:

         1. (i) request a standard fair hearing before, after, or at the same time as the request for an appeal to the MCO;
         2. (ii) request an expedited fair hearing only after completing the MCO's appeal process.
      4. (D) when an adverse determination is made by an operating agency or its designee with regard to the preadmission screening and annual resident review; or
      5. (E) when a determination is made by a skilled nursing facility or nursing facility to transfer or discharge a resident.

   2. (2) Expedited fair hearings. An individual enrolled in a Medicaid MCO may request an expedited fair hearing when:

      1. (A) the MCO determines or the provider indicates that taking the time for a standard appeal and/or fair hearing could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function; and
      2. (B) the individual has exhausted his or her expedited MCO appeal rights.

2. (b) Scope.

   1. (1) These rules establish fair hearing procedures , which an operating agency will follow when the operating agency is required to conduct a fair hearing for Medicaid-funded services.
   2. (2) An individual's authorized representative, as defined by the operating agency, may, on the individual's behalf, take any step that the individual can take as described in these rules.

Source Note:The provisions of this §357.1 adopted to be effective March 31, 1999, 24 TexReg 2293; amended to be effective November 16, 2003, 28 TexReg 9806.