The executive commissioner must adopt Medicaid fair hearing rules that give applicants and recipients due process, require specific notice content and timing, and limit when services can be stopped before a hearing decision.
Sec. 532.0302. UNIFORM FAIR HEARING RULES. (a) The executive commissioner shall adopt uniform fair hearing rules for Medicaid-funded services. The rules must provide: (1) due process to a Medicaid applicant and to a recipient who seeks a Medicaid service, including a service that requires prior authorization; and (2) the protections for applicants and recipients required by 42 C.F.R. Part 431, Subpart E, including requiring that: (A) the written notice to an individual of the individual's right to a hearing must: (i) contain an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and (ii) be delivered by mail, and postmarked at least 10 business days, before the date the individual's Medicaid eligibility or service is scheduled to be terminated, suspended, or reduced, except as provided by 42 C.F.R. Section 431.213 or 431.214; and (B) if a hearing is requested before the date a recipient's service, including a service that requires prior authorization, is scheduled to be terminated, suspended, or reduced, the agency may not take that proposed action before a decision is rendered after the hearing unless: (i) it is determined at the hearing that the sole issue is one of federal or state law or policy; and (ii) the agency promptly informs the recipient in writing that services are to be terminated, suspended, or reduced pending the hearing decision. (b) The commission shall develop a process to address a situation in which: (1) an individual does not receive adequate notice as required by Subsection (a)(2)(A); or (2) the notice required by Subsection (a)(2)(A) is delivered without a postmark. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.