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 TB/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 effectively and promptly address all client requests for appeals.

This policy is not intended to address allegations filed against the Section or its Branches regarding staff actions or to be used to request a change or modification of a decision, policy, or procedure for programs outside of THMP. This policy should also not be used for purposes of filing a complaint.  For complaints, follow 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

Investigation – The process of gathering information sufficient to allow a decision to be made regarding the validity of the request for appeal.

TB/HIV/STD Section – A Section in the DSHS Laboratory and Infectious Disease Services Division which includes the HIV/STD Prevention and Care Unit, the HIV/STD/HCV Epidemiology and Surveillance Branch, the TB and Hansen’s Disease Branch, and the Pharmacy Branch.
 

4.0 Persons Affected

• TB/HIV/STD Section employees
• Section Unit Managers
• THMP Applicants
   

5.0 Right to Appeal

An applicant or client whose application for initial benefits (or renewal application) is denied, or whose services have been terminated by the department, will receive a denial letter from THMP.  The appeals process will be outlined in this letter. 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 department's HIV/STD Prevention and Care Unit that the person wishes to dispute the program's decision. The written notice must contain all arguments and supporting documents being put forward by the individual in question for the appeal. The notice should be addressed to the Department of State Health Services, HIV/STD Prevention and Care 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

The department is not required to offer an opportunity to dispute the decision to deny, non-renew or terminate if the department's actions are the result of the exhaustion of program funds.
 

5.2 DSHS Staff Procedures

Any TB/HIV/HIV Section staff receiving a request for a THMP appeal by phone or email must record all the details on the Complaint Intake Form, 020-050A . The staff receiving the complaint shall immediately take the complaint to a department review panel member who will contact the individual requesting an appeal and explain the process for submitting an appeal.
 

5.3 Department Review Panel

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

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

In the event of an agency reorganization, equivalent positions will be used.
 

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 will issue a written decision. The panel's decision shall be final.
 

5.6 Notify Appropriate Individual(s) of Findings/Resolution

When appropriate action has been determined, the resolution is approved by the Committee and documented in writing. Written notification of findings and recommended action are sent to the appropriate individual. All letters regarding the findings and resolution may be signed by the HIV/STD Prevention and Care Unit Director.
 

5.7 Closing the Appeals Request

The committee writes a summary to document the review of the client’s appeal of the eligibility determination, including results of the investigation. All supporting documents are filed with the appeals request and are forwarded to the Committee. The committee signs and forwards to the Section Staff Services Officer for closing of complaint and filing. The Staff Services Officer will also be responsible for preparing appropriate record retention schedules and disposition of appeal files once the required retention period is reached.
 

5.8 Resolution Time Frames

The following resolution time frames should be followed:

If the investigation cannot be completed within the appropriate time frame, the assignee should notify the complainant in writing. A copy should be sent to the Section Staff Service Officer.  
 

6.0 History