Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL
Section 354.2407 - Recipient Rights

Universal Citation: 1 TX Admin Code ยง 354.2407

Current through Reg. 49, No. 38; September 20, 2024

(a) The Health and Human Services Commission (HHSC) gives a recipient timely and adequate notice of an action to assign the recipient to a designated provider and opportunity for a fair hearing. Hearings are conducted under Chapter 357, Subchapter A, of this title (relating to Uniform Fair Hearing Rules).

(1) The written notice to a recipient of the recipient's right to a hearing will be mailed at least ten calendar days before the lock-in period effective date.

(2) HHSC will grant a hearing if it receives a recipient's request for a hearing no later than:
(A) 90 calendar days from the date of the initial notice of intent to assign a designated provider; or

(B) 90 calendar days from the date of the notice of intent to continue a lock-in period.

(3) If a request for a hearing is received by the lock-in effective date, HHSC will not implement the lock-in status until the hearing has been held and a final decision rendered.

(4) If a request for a hearing is received after the lock-in effective date, the lock-in status will remain in effect until the hearing has been held and a final decision rendered that reverses the lock-in action.

(5) The recipient does not have the right to a fair hearing when the lock-in is the result of a misdemeanor or felony offense related to fraud and/or abuse of Medicaid benefits and/or services, or to controlled substances.

(6) During the lock-in period, the recipient is not entitled to a fair hearing for denial of either of the following requests:
(A) change in designated provider; or

(B) termination of the lock-in period.

(b) A lock-in recipient must have reasonable access to Medicaid services and benefits and must be able to receive emergency services for an emergency medical condition. A provider other than the designated providers may provide the emergency services. The emergency care provider must certify that the recipient required emergency services for an emergency medical condition.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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