| (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.
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| 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 |
