Texas Medicaid Appeals

If you apply for Medicaid benefits in Texas and get denied you can appeal. There are limited time periods for an appeal, or fair hearing, to be requested. The applicant has 90 calendar days from the date on the notice of the adverse action to request an appeal. If the appellant was already receiving Medicaid benefits and the adverse action is a removal or reduction of benefits, then the appellant can preserve his pre-action benefits during the pendency of the appeal by requesting the hearing within 13 days of the date of the notice of adverse action. So, a Notice from HHSC has to be reviewed immediately and a decision needs to be made right away.

Once the appeal process begins it is HHSC’s burden to prove that their decision was correct. The hearing officer will not have the entire file; she/he will only have the documents submitted by HHSC and the Applicant specifically for the appeal. It is important for the Applicant to submit all documents that support their position. Documents should be exchanged at least 20 days prior to the hearing date, and continuances can be requested if necessary.

Hearings are usually conducted telephonically. The hearing officer is an HHSC employee who is not part of the Medicaid eligibility department (DADS) and is supposed to be impartial. The department is represented by either a caseworker, supervisor or special member of the staff designated as a representative for these purposes. Hearings can last anywhere from 20 minutes to 2 hours, depending on the issues involved, and they can be continued to a later date, if necessary. The appellant can represent himself or be represented by a responsible party or an attorney.

HHSC has an online Fraud and Fair Hearings Handbook, which, along with the MEPD Handbook, contains more information about appeals.

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