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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 354MEDICAID HEALTH SERVICES
SUBCHAPTER IMEDICAID PROGRAM APPEALS PROCEDURES
DIVISION 2RECIPIENT NOTICE AND FAIR HEARING
RULE §354.2211Recipient Notice and Fair Hearing Request

(a) When notice is required. A Medicaid-eligible recipient is entitled to a notice under this subchapter any time the department, its designee, or a managed care organization (MCO) intends to take an action. An MCO is responsible for sending the notice to recipients enrolled in the MCO. The department is responsible for sending notices to all other recipients.

(b) Time of notice. A notice of intent to take action must be mailed to the recipient by the department, its designee or MCO no less than 30 days before the department, its designee, or MCO intends to take an action.

(c) Content of notice. The notice required by subsection (a) of this section must contain the following information:

  (1) a statement of the action the department, its designee, or MCO will take;

  (2) an explanation of the reasons the department, its designee, or MCO will take an action;

  (3) a reference to the state or federal regulations which support the action the department, its designee, or MCO will take;

  (4) an explanation of the recipient's right to request a fair hearing from the department;

  (5) the procedure by which the recipient may request a fair hearing from the department or through the MCO, including the address where written requests must be submitted and any toll-free or local phone number the recipient may call to request assistance or a fair hearing;

  (6) an explanation that recipients may represent themselves or have legal counsel, a relative, a friend, or another spokesperson represent them;

  (7) an explanation of whether and under what circumstances services may be continued if a fair hearing is requested;

  (8) a statement that the recipient must make a request for a fair hearing within 30 days from the date on the notice, and that if the recipient does not request a fair hearing within this time period, the recipient's right to a fair hearing will be waived. The notice is presumed to be received by the recipient five days from the date of the notice;

  (9) an explanation that the recipient may request the fair hearing be conducted based on written information without the necessity of taking oral testimony. The written information may consist of the department's records, the medical information submitted by the recipient, and any additional written information the recipient may wish to submit; and

  (10) a notice from an MCO informing recipients of their right to access the department's fair hearing process under §36.23 of this title (relating to Fair Hearings).

(d) Resolution prior to fair hearing. The department will make every effort to informally resolve the action before the fair hearing date.

(e) Emergency Procedure.

  (1) Actions relating to emergencies will be handled by the department on an expedited basis.

  (2) The department, its designee or the MCO will give the recipient notice of their right to a fair hearing as required by this section by the most expedient means available to the recipient, including by telephone.

  (3) The recipient may request a fair hearing by the most expedient means available to the recipient, including by telephone.


Source Note: The provisions of this §354.2211 adopted to be effective May 29, 1997, 22 TexReg 4369; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562

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