SECTION 354.2407. Recipient Rights

(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.

Source Note: The provisions of this §354.2407 adopted to be effective April 2, 2000, 25 TexReg 2817; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4563; amended to be effective April 6, 2003, 28 TexReg 2738; amended to be effective April 2, 2013, 38 TexReg 2095