TX HHS Form 4801. State Fair Hearing Evidence Packet Cover Page

The TX HHS Form 4801, State Fair Hearing Evidence Packet Cover Page, is used to provide supporting documentation for a state fair hearing appeal related to the Medically Dependent Children Program (MDCP) or STAR+PLUS Home and Community Based Services (HCBS) Program. This form helps individuals who have had their eligibility denied to gather evidence and prepare for a fair hearing.

The packet includes copies of key documents, such as Form H2065-D, Notice of Managed Care Program Services Policy, which outlines the rules used to determine the eligibility decision being appealed. The packet also contains information about the state fair hearing process, including notification of the hearing date and time, and instructions on how to dial into the hearing.

This form is intended for use by individuals who have had their eligibility denied in a MDCP or HCBS Program and wish to appeal the decision through a state fair hearing. The attached packet should be kept with you during the hearing, as HHSC representatives may testify about the documents included, and you will have the right to ask questions and provide your own testimony.