2021.01 Appeals Requests Related to the Texas HIV Medication Program

1.0 Purpose

The purpose of this procedure is to document the client’s appeal process and provide the HIV/STD Section (Section) with a method of resolving client requests for appeals for a Texas HIV Medication Program (THMP) eligibility determination. It is the policy of the Section to address client requests for appeals effectively and promptly.

The Section does not intend this policy to address allegations filed against the Section or its units regarding staff actions or to be used to request a change or modification of a decision, policy, or procedure for programs outside of THMP. The Section also does not intend this policy for the purpose of filing a complaint. For complaints, follow Section procedure 020.050, Public Complaints Related to the Delivery of Section Programs.
 

2.0 Authority

The Texas Administrative Code Rule 98.118 Texas HIV Medication Program Appeals Procedure and Rule 98.12 Texas State Pharmacy Assistance Program Appeals Procedures and Exceptions.
 

3.0 Definitions

Appeal – A request to have a program denial or rejection reviewed.

Department Review Panel – The department review panel is a group of DSHS staff tasked with the investigation, documentation, and final decision for appeals.

Investigation – The process of gathering information sufficient to allow the Department Review Panel to decide the validity of the request for appeal.

HIV/STD Section – A Section within the Infectious Disease Prevention Division of the Texas Department of State Health Services (DSHS) which includes the HIV Care and Medications Unit, the HIV/STD/HCV Epidemiology and Surveillance Unit, HIV/STD Prevention Unit, and the Pharmacy Unit.
 

4.0 Persons Affected

• HIV/STD Section Staff
• Section Unit Managers
• THMP Applicants
   

5.0 Right to Appeal

An applicant or client whose application for initial benefits (or renewal application) THMP denies or whose services THMP terminates receives a denial letter from THMP.  This letter outlines the appeals process. Applicants may appeal the program's decision.

An applicant, client, or person legally responsible for an applicant or client may initiate the appeal process by notifying the HIV Care and Medications Unit that the person wishes to dispute the program's decision. The written notice must contain all arguments and supporting documents the individual in question puts forward for the appeal. Appellants send this notice to the Department of State Health Services, HIV Care and Medications Unit, Texas HIV Medication Program, Attn: MSJA, Mail Code 1873, P.O. Box 149347, Austin, Texas, 78714-3947.
 

5.1 Limits to Right to Appeal

DSHS does not require THMP to offer an opportunity to dispute the decision to deny, non-renew or terminate if THMP’s actions are the result of the exhaustion of program funds.
 

5.2 DSHS Staff Procedures

HIV/STD Section staff receiving a request for a THMP appeal by phone or email record the details on the Complaint Intake Form, 020-050A . The staff receiving the complaint immediately take the complaint to a department review panel member who contacts the individual requesting an appeal and explains the process for submitting an appeal.
 

5.3 Department Review Panel

A department review panel hears the appeal. The panel shall consist of:

• the HIV/STD Section Director
• the HIV Care and Mediations Unit Director
• the Texas HIV Medication Program Manager
• the Infectious Disease Prevention Division Medical Officer

If the agency reorganizes, the department review panel includes equivalent positions.
 

5.4 Rights of the Appellant

The appellant may present the case in person before the panel, or rely on the written submissions, but in either event the issues on appeal and the arguments in support of those issues are limited to those already submitted in writing.
 

5.5 Department Review Decision 

Following review of the materials, and hearing from the individual in person (if applicable), the panel issues a written decision. The panel's decision shall be final.
 

5.6 Notify Appropriate Individual(s) of Findings and Resolution

When the panel has determined the appropriate action, the panel approves the resolution and documents it in writing. Section staff send the written notification of findings and recommended action to the appropriate individual. The HIV Care and Medications Unit Director signs letters regarding the findings and resolution.
 

5.7 Closing the Appeals Request

The panel writes a summary to document the review of the client’s appeal of the eligibility determination, including results of the investigation. The panel or designated staff files supporting documents with the appeals request. The committee signs and forwards the summary and supporting documents to the Section Staff Services Officer for closing of complaint and filing. The Staff Services Officer is also responsible for preparing appropriate record retention schedules and the disposition of appeal files once the required retention period ends.
 

5.8 Resolution Time Frames

The panel follows these timeframes when reviewing an appeals request:

If the panel cannot complete the investigation within the appropriate time frame, the THMP Manager notifies the appellant in writing and sends a copy to the Section Staff Service Officer.  
 

6.0 History