Section 1000, STAR Kids Overview and Eligibility

Revision 19-10; Effective June 14, 2019

 


Senate Bill 7 from the 83rd Legislature, Regular Session, in 2013, required the Texas Health and Human Services Commission (HHSC) to create the State of Texas Access Reform (STAR) Kids program. STAR Kids is a Medicaid managed care program for children with disabilities in Texas, which integrates acute care and long term services and supports (LTSS) delivered by a managed care organization (MCO).

STAR Kids does not change or impact an individual’s Medicaid eligibility, nor does STAR Kids impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, age birth through 20, enrolled with a STAR Kids MCO, are called members of the MCO. All STAR Kids members have access to service coordination provided by an MCO employee or through a member’s primary care provider, authorized by the MCO.

Service coordination is specialized care management performed by an  MCO service coordinator and includes, but is not limited to:

All STAR Kids members receive an annual comprehensive assessment of their physical and functional needs by an MCO service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI). Within the time frame listed in the STAR Kids Contract, Section 8.1.39, STAR Kids Initial Screening and Assessment Process, if a member has a change in their physical or behavioral health, a change in functional ability or caregiver supports, the MCO must reassess the member and update their ISP, as applicable, and authorize necessary services upon request from the member, legally authorized representative (LAR), authorized representative (AR) or health home.

In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering additional services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP provides respite, Flexible Family Support Services (FFSS), adaptive aids, minor home modifications, employment services and Transition Assistance Services (TAS) to children and young adults who meet the level of care (LOC) provided in a nursing facility (NF) so he or she can safely live in the community. The state of Texas appropriates the program a limited number of slots, so HHSC maintains an interest list of MDCP applicants. A child, young adult, LAR or AR may ask their MCO about how to be placed on the MDCP interest list at any time or call the HHSC Interest List Management (ILM) Unit staff’s toll-free number at 1-877-438-5658.

 

1100 Legal Basis and Values

Revision 18-0; Effective September 4, 2018

STAR Kids Medicaid Managed Care Program is required by Texas Government Code §533.00253. Title 1 Texas Administrative Code (TAC) §353, Subchapter M, Home and Community Based Services in Managed Care, and Subchapter N, STAR Kids, outline the delivery of STAR Kids services, as well as  Medically Dependent Children Program (MDCP) services. Requirements pertaining to managed care organizations (MCOs) are outlined in the STAR Kids Managed Care Contract.

The STAR Kids Program Support Unit Operational Procedures Handbook includes operational procedures for the Texas Health and Human Services Commission (HHSC) Program Support Unit (PSU) staff.

The STAR Kids Handbook includes policies and procedures to be used by managed care organizations (MCOs), contractors and service providers in the delivery of STAR Kids MDCP services to eligible members.

 

1110 Mission Statement

Revision 18-0; Effective September 4, 2018
 
The mission of Texas Health and Human Services Commission (HHSC) is to provide individually appropriate Medicaid managed care services to children and young adults with disabilities to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR Kids program is established to:

 

1120 Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

The Medically Dependent Children Program (MDCP) is a home and community based services program authorized under §1915(c) of the Social Security Act. MDCP provides respite, Flexible Family Support Services (FFSS), minor home modifications, adaptive aids, Transition Assistance Services (TAS), employment assistance (EA), supported employment (SE) and financial management services (FMS) through a STAR Kids managed care organization (MCO). This section provides an overview of MDCP, including its eligibility requirements.

 

1130 Medically Dependent Children Program Goal

Revision 18-0; Effective September 4, 2018

The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults age 20 and younger who are medically dependent, and to encourage de-institutionalization of children and young adults who reside in nursing facilities (NFs).
MDCP accomplishes this goal by:

 

1200 Medically Dependent Children Program Eligibility

Revision 18-0; Effective September 4, 2018

An individual becomes eligible to be assessed for Medically Dependent Children Program (MDCP) services when their name reaches to the top of the MDCP interest list. An individual is placed on the interest list by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if he or she is already enrolled in STAR Kids. Once an individual’s name reaches the top of the interest list, the individual selects an MCO who beings the determination of eligibility as the individual applies for services. An individual going through the application and eligibility process for STAR Kids is referred to as an applicant. An individual enrolled in STAR Kids is referred to as a member.

MDCP is provided by virtue of authority granted to the state of Texas to allow delivery of long term services and supports (LTSS) that assist members to live in the community in lieu of a nursing facility (NF). To be eligible for services under MDCP, the applicant or member must meet the following criteria:

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F), states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

 

1210 Medical Necessity Determination

Revision 19-10; Effective June 14, 2019
 
A Medically Dependent Children Program (MDCP) applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before admission into the MDCP. The determination of MN is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The applicant’s or member’s individual service plan (ISP) cost limit is calculated based on information gathered through the SK-SAI MDCP module.

The managed care organization (MCO) completes and submits the SK-SAI to Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care (LTC) Online Portal for MDCP applicants or members. TMHP processes the SK-SAI for applicants or members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in §1915(c) Medicaid waiver programs to categorize needs for applicants or members and establish the ISP cost limit.

When TMHP processes an SK-SAI, a three-alphanumeric digit RUG is generated and appears in the TMHP LTC Online Portal, as well as the MCO response file. An SK-SAI with incomplete RUG information results in a "BC1" code instead of a RUG value. An SK-SAI resulting in a “BC1” code does not have all of the information necessary for TMHP to accurately calculate a RUG for the member. A “BC1” code is not a valid RUG to determine MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a “BC1” code. The MCO nurse must also submit any corrections to SK-SAI items used to determine MN within 14 days. After 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to TMHP. See the STAR Kids Handbook, Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for detailed instructions pertaining to the MCO communicating inactivation and corrections to the SK-SAI to TMHP.

Applicants without Medicaid require a Medicaid eligibility financial determination. For these individuals, the HHSC Program Support Unit (PSU) staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when the applicant meets MN. This notification is documented on Form H1746-A, MEPD Referral Cover Sheet, which PSU staff fax to the MEPD specialist. This process is outlined in more detail in Section 2210, Income and Resource Verifications for Medicaid Eligibility.

 

1211 Medical Necessity Determination for an Applicant or Member Residing in a Nursing Facility

Revision 19-10; Effective June 14, 2019
 
During initial contact with the applicant or member, the managed care organization (MCO) service coordinator must explore the applicant’s or member’s status in the nursing facility (NF) and desire to transition to the community. The MCO service coordinator completes the STAR Kids Screening and Assessment Instrument (SK-SAI) and submits the assessment to Texas Medicaid & Healthcare Partnership (TMHP) indicating a request for a determination of medical necessity (MN). This process is described in more detail in the STAR Kids Handbook, Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

 

1212 Medical Necessity Determination for an Applicant or Member Not Residing in a Nursing Facility

Revision 18-0; Effective September 4, 2018
 
For applicants or members not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the STAR Kids Screening and Assessment Instrument (SK-SAI) completed by the managed care organization (MCO) selected by the applicant or member.

The MCO must electronically submit the SK-SAI to TMHP through the TMHP Long Term Care (LTC) Online Portal indicating a request for MN determination after obtaining a physician signature using Form 2601, Physician Certification. The SK-SAI and Form 2601 must be retained in the MCO’s records.

 

1220 Individual Cost Limit

Revision 18-0; Effective September 4, 2018
 
The cost of Medically Dependent Children Program (MDCP) services on the STAR Kids individual service plan (ISP) cannot exceed 50 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the managed care organization (MCO) service coordinator must develop an ISP consisting of MDCP services requested by the applicant and the cost of those services. The cost must be developed at or below 50 percent of the cost to provide services to the applicant, based on the Resource Utilization Group (RUG) in an NF.

Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if the Medicaid state plan services and the MDCP services would pose a risk to the individual’s health, safety or welfare.

 

1230 Unmet Need for at Least One Medically Dependent Children Program Service

Revision 18-0; Effective September 4, 2018
 
The §1915(c) Medically Dependent Children Program (MDCP) waiver specifies that individuals must have a need for at least one MDCP service to receive MDCP waiver services. For initial and continued eligibility for the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. Therefore, an MDCP ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, will be rejected. Members who do not use at least one MDCP service per ISP year are subject to disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for medical assistance only (MAO) Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a §1915(c) Medicaid waiver program must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) §441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all MDCP waiver requirements and also must receive one MDCP waiver service per month.

 

1240 Age

Revision 18-0; Effective September 4, 2018
 
To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

 

1250 Citizenship and Identity Verification

Revision 18-0; Effective September 4, 2018
 
As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long term services and supports (LTSS) members whose financial eligibility is based on a determination from the Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Verification of citizenship and identity for Medically Dependent Children Program (MDCP) eligibility purposes is a one-time activity conducted by Medicaid for the Elderly and People with Disabilities (MEPD), as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD specialists, verification is no longer required even after a break in eligibility. Therefore, applicants who are active Medicaid, Medicare or Supplemental Security Income (SSI) recipients do not require citizenship verification since verification occurred upon entry of those programs.

 

1260 Living Arrangement and Texas Residency

Revision 18-0; Effective September 4, 2018
 
The applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services as outlined in Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(B), Medically Dependent Children Program.

If the applicant is under age 18, the applicant must not live in a foster home that includes more than four children unrelated to the applicant, as outlined in Title 1 TAC §353.1155(b)(1)(G)(ii).

Managed care organization (MCO) service coordinators must confirm the applicant or member, if under age 18, lives with a family member, such as a parent, guardian, grandparent or sibling, as defined in the Glossary. The MCO service coordinator must review guardianship documentation or obtain a statement from the applicant, member, legally authorized representative (LAR), authorized representative (AR) or family member regarding relation. The MCO service coordinator must maintain this documentation in the member’s case file.

 

1270 Financial Eligibility

Revision 18-0; Effective September 4, 2018
 
Applicants or members who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. Program Support Unit (PSU) staff must determine if an applicant or member is currently on Medicaid and check the Texas Integrated Eligibility Redesign System (TIERS) to confirm the current status of an applicant or member. A Medicaid for the Elderly and People with Disabilities (MEPD) determination may have already been completed for an applicant or member and must be used unless there have been changes in the applicant’s or member’s financial situation.

If the applicant does not have a Medicaid eligibility determination, it is PSU staff’s responsibility to assist the applicant with completing the application and obtaining the necessary verifications to establish eligibility from MEPD specialists. These processes are described in Section 2100, Enrollment Following Release from the Interest List.

 

1300 STAR Kids Services and Service Delivery Options

Revision 18-0; Effective September 4, 2018
 
STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service (FSS) Medicaid, described in the Texas Medicaid state plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).

 

1310 Acute Care Services

Revision 18-0; Effective September 4, 2018
 
STAR Kids members may receive medically necessary services through their managed care organization (MCO), and as required under Title 42 Code of Federal Regulations (CFR) §441, Subpart B, Early and Periodic Screening, Diagnostics and Treatment (EPSDT) of Individuals Under Age 21. This includes, but is not limited to:

STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members will receive dental care through their primary insurer, their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service (FSS) model.

 

1320 Long Term Services and Supports

Revision 18-0; Effective September 4, 2018
 
STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):

STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI and who meet an institutional level of care (LOC), may receive the following services through their STAR Kids MCO:

STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in an NF. Receipt of MDCP services does not impact a member’s eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP include:

 

1330 Service Delivery Options for Certain Long Term Services and Supports

Revision 18-0; Effective September 4, 2018
 
STAR Kids provides members with an array of services, as identified on each member’s individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.

STAR Kids members may choose from three service delivery options for the delivery of certain long term services and supports (LTSS). The options available are the Agency Option (AO), Service Responsibility Option (SRO) and Consumer Directed Services (CDS) option. State plan LTSS which can be delivered through these service delivery options are:

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:

STAR Kids members, legally authorized representatives (LARs) or authorized representatives (ARs) may choose to participate in the AO, CDS option or SRO delivery models.

Members who choose the AO model select an MCO-contracted agency to coordinate service delivery for the services on their ISP.

In the CDS option model, the member, LAR or AR work with assistance from a financial management services agency (FMSA). FMSA personnel may be employed directly by or through personal service agreements or subcontracts with the providers. Members who choose the CDS option model are given the authority to self-direct certain services. If the member chooses to self-direct certain services, the MCO coordinates delivery of non-member directed services.

In the SRO model, an agency is the attendant’s employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to agency policies and standards before mailing them to the member’s home. The member, LAR, or AR is responsible for most of the day-to-day management of the attendant’s activities, beginning with interviewing and selecting the person who will be the attendant.

More information about these service delivery options is available in Section 5000, Service Delivery Options.

 

1400 Service Coordination through the Managed Care Organization

Revision 18-0; Effective September 4, 2018
 
All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide some service coordination functions through the member’s health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the MCO service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members, legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing facility (NF) or other long-term care facility, the MCO service coordinator must inform the member, LAR or AR about options available through home and community based services programs, in addition to facility-based options.

MCO service coordinators are responsible for assessing a member’s needs using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP. During the annual face-to-face visit, the MCO service coordinator must:

 

1410 Service Coordination Requirements

Revision 18-0; Effective September 4, 2018
 
Managed care organizations (MCOs) provide a different level of service coordination, depending on a member’s needs. Members with more complex needs receive more service coordination than members whose needs are less complex.

Members with the highest needs are designated as Level 1 members in the STAR Kids Managed Care Contract. These members receive a minimum of four face-to-face visits from a named MCO service coordinator annually, in addition to monthly telephone calls, unless otherwise requested by a member, legally authorized representative (LAR) or authorized representative (AR). Level 1 MCO service coordinators must be a registered nurse (RN), nurse practitioner (NP), physician’s assistant (PA), social worker (MSW, LCSW or LBSW), or licensed professional counselor (LPC) if the member’s service needs are primarily behavioral. Level 1 members include those who:

Level 2 members have specialized needs that are less complex than Level 1 members. Level 2 members receive a minimum of two face-to-face visits and six telephonic contacts annually from a named MCO service coordinator, unless otherwise requested by the member, LAR or AR. Level 2 MCO service coordinators must be either an RN, NP, PA, have an undergraduate or graduate degree in social work or a related field, or be a licensed vocational nurse (LVN) with previous service coordination or case management experience. Level 2 members include members who:

Level 3 members have fewer needs than Level 2 members. MCOs are required to provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make three telephonic contacts annually, at minimum. Level 3 MCO service coordinators must have a minimum of a high school diploma or a general education diploma (GED) and direct experience working with children and young adults with similar conditions or behaviors in three of the last five years.

Members receiving Level 1 or Level 2 service coordination must have a single named person as their assigned MCO service coordinator. Level 3 members, LARs or ARs may request a single named MCO service coordinator by calling the service coordination hotline on the back of their STAR Kids member ID card. In addition, the MCO must provide a named service coordinator for members who qualify for Level 3 who reside in a nursing facility (NF) or community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who are served by one of the following non-capitated §1915(c) Medicaid waiver programs: Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS) or Texas Home Living (TxHmL). The MCO must notify members within five business days of the name and telephone number of the new MCO service coordinator, if the service coordinator changes.

MCOs must notify all members in writing of the:

 

1420 Service Coordination and Programs Serving Members with Intellectual or Developmental Disabilities

Revision 18-0; Effective September 4, 2018
 
Members who have intellectual and developmental disabilities (IDD) living in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or who receive services through one of the following IDD waivers, receive their acute care services and some long term services supports (LTSS) (e.g., private duty nursing (PDN)) through STAR Kids and continue to receive most of their LTSS through the following programs:

A member with IDD that meets the above criteria has a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member, legally authorized representative (LAR) or authorized representative’s (AR’s) personal preference.

These members also have a person(s) outside of the MCO who develops and implements a service plan and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member’s IDD waiver case manager or service coordinator. The member’s IDD waiver case manager or service coordinator should invite MCO service coordinators to their care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in-person or telephonically. The MCO service coordinator is responsible for the coordination of these members’ acute care services and capitated LTSS.

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states that Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one §1915(c) Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

 

1430 Service Coordination and the Youth Empowerment Services Waiver Program

Revision 18-0; Effective September 4, 2018
 
A member who receives services through the Youth Empowerment Services (YES) waiver program receive their acute care services and some long term services and supports (LTSS) (e.g., Day Activity and Health Services (DAHS), private duty nurse (PDN), and Community First Choice (CFC)) only through STAR Kids and continues to receive their waiver services through the YES waiver program. A member served by the YES waiver program will have a named managed care organization (MCO) service coordinator and is considered a Level 1 member.

YES waiver program members also have a case manager outside of the MCO who develops and implements the YES waiver service plan and monitors YES waiver service delivery. This case management is provided through the capitated Mental Health Targeted Case Management (MHTCM) benefit, which the MCO must authorize for any member receiving YES waiver program services. The MCO service coordinator must respond to requests from the member’s YES waiver case manager. The member’s YES waiver case manager should invite the MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be either in-person or telephonically. The MCO service coordinator is responsible for the coordination of these member’s acute care services and capitated LTSS.

 

1440 Service Coordinators and Home and Community Based Services - Adult Mental Health

Revision 18-0; Effective September 4, 2018
 
The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves members who have serious and persistent mental illness (SPMI) and:

HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program’s population. HCBS-AMH is operated on a fee-for-service (FFS) basis for members age 18 and up. Each participant is assigned a recovery manager (RM) who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive their acute care services through their managed care organization (MCO) and their enhanced community-based services from providers contracted with the Texas Department of State Health Services (DSHS). Additional information about HCBS-AMH can be found at https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

 

1441 Program Point of Contact

Revision 18-0; Effective September 4, 2018

Each managed care organization (MCO) must have a designated program point of contact (PPOC) for the Home and Community Based Services - Adult Mental Health (HCBS-AMH) program. The PPOC is responsible for:

 

1442 Managed Care Organization Service Coordination Responsibility

Revision 18-0; Effective September 4, 2018

Managed care organization (MCO) service coordinators must participate in telephonic recovery plan meetings, as scheduled by Texas Health and Human Services (HHSC) or recovery managers (RMs), and provide any requested member-specific information prior to the meeting. MCO service coordinators must:

HCBS-AMH may provide transitional planning for members who reside in an institution and also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the RM, telephonically or in-person, during the member’s stay. Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution. MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR Kids MCOs must follow all discharge planning requirements, as outlined in the STAR Kids Managed Care Contract, Section 8.1.38.10.

 

1600 Disclosure of Information

Revision 18-0; Effective September 4, 2018

 

 

1610 Confidential Nature of Medical Information - Health Insurance Portability and Accountability Act

Revision 18-0; Effective September 4, 2018
 
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to secure the confidentiality of protected health information (PHI). PHI is information that identifies or could be used to identify an applicant or member and that relates to the:

PHI includes an applicant or member’s date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number, and demographic data.

 

1611 Confidential Nature of a Case Record

Revision 18-0; Effective September 4, 2018
 
Information collected in determining initial or continuing eligibility is confidential. The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about or does not specifically identify an applicant or member. An applicant, member, legally authorized representative (LAR) or authorized representative (AR) may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.

 

1612 Custody of Records

Revision 18-0; Effective September 4, 2018
 
Texas Health and Human Services Commission (HHSC) staff must use reasonable diligence to safeguard, protect and preserve records and prevent disclosure of the protected health information (PHI) he or she contain, except as provided by the HHSC regulations.

Reasonable diligence for employees responsible for records includes keeping records:

 

1613 Responsible Party to Authorize Disclosure

Revision 18-0; Effective September 4, 2018

 

 

1613.1 Legally Authorized Representatives and Authorized Representatives

Revision 18-0; Effective September 4, 2018
 
Only the member’s legally authorized representative (LAR) or authorized representative (AR) can exercise the applicant’s or member’s rights with respect to protected health information (PHI). Therefore, only an applicant, member, LAR or AR may authorize the use or disclosure of PHI or obtain PHI on behalf of an applicant or member. Exception: Texas Health and Human Services Commission (HHSC) is not required to disclose the information to the LAR or AR if the applicant or member is subjected to domestic violence, abuse or neglect by the LAR or AR. Consult HHSC Privacy Office, as described in Section 1615, Information That May Be Disclosed, if it is believed that health information should not be released to the LAR or AR.

Note: A responsible party is not automatically an LAR or AR.

 

1613.2 Unemancipated Minors

Revision 18-0; Effective September 4, 2018

A parent is the legally authorized representative (LAR) for a minor child except when:

 

1613.3 Adults and Emancipated Minors

Revision 18-0; Effective September 4, 2018
 
If the applicant or member is an adult or emancipated minor, including married minors, the applicant’s or member’s legally authorized representative (LAR) or authorized representative (AR) is a person who has the authority to make health care decisions about the member and includes a:

Consult Texas Health and Human Services Commission (HHSC) Privacy Office, as described in Section 1615, Information That May Be Disclosed, for approval.

 

1613.4 Deceased Applicant or Member

Revision 18-0; Effective September 4, 2018
 
The legally authorized representative (LAR) or authorized representative (AR) for a deceased applicant or member is an executor, administrator or other person with authority to act on behalf of the applicant, member or the member’s estate. These include:

Consult Texas Health and Human Services Commission (HHSC) Privacy Office, as described in Section 1615, Information That May Be Disclosed, about whether a particular person is the LAR or AR of an applicant or member.

 

1614 Verifying the Identity of an Applicant, Member, LAR, AR or Third Party Individual

Revision 18-0; Effective September 4, 2018

 

 

1614.1 Telephone Communication

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must establish the identity of an individual who identifies himself or herself as an applicant, member, legally authorized representative (LAR) or authorized representative (AR) by verifying the individual’s knowledge of two of the following:

Establish the identity of an attorney, LAR or AR by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the applicant or member.

 

1614.2 In-Person Communication

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff must establish the identity of the individual who presents himself or herself as an applicant, member, legally authorized representative (LAR) or authorized representative (AR) at a Texas Health and Human Services Commission (HHSC) office by examining two forms of identification with at least one form of identification being a government-issued photo identification (ID):

Establish the identity of other HHSC or MCO staff, federal agency staff, researchers or contractors by examining at least one source such as:

Identify the need for other HHSC or MCO staff, federal staff, research staff or contractors to access confidential information through one of the following:

Contact the HHSC Office of Chief Counsel when federal agency staff, contractors, researchers or other HHSC or MCO staff come to the office without prior notification or adequate identification and request permission to access records.

 

1614.3 Electronic Mail Communication

Revision 18-0; Effective September 4, 2018

If Program Support Unit (PSU) staff receive electronic mail, also known as email, from an applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party that contains protected health information (PHI), PSU staff must respond using the following procedures:

PSU staff must not send PHI by email to non-government entity individuals, including applicants, members, LARs, ARs or third-party individuals. Refer to Section 1616, Verification and Documentation of Disclosure, for approved methods of transmitting PHI to applicants, members, LARs, ARs, and third party individuals to whom the applicant, member, LAR or AR have provided written consent for the release of PHI.

PSU staff may share PHI by email with Medicaid for the Elderly and People with Disabilities (MEPD), Texas Medicaid & Healthcare Partnership (TMHP), managed care organization (MCO) the applicant or member is enrolled with, and other Texas Health and Human Services Commission (HHSC) staff for work-related purposes, but only if the email:

Password-protected documents sent by email and electronic fax (e-fax) documents are not considered a secure method for transmitting PHI.

 

1615 Information That May Be Disclosed

Revision 18-0; Effective September 4, 2018

Reasonable effort must be made to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to determine eligibility and operate the program. The disclosure of the applicant or member’s PHI from the Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant or member.

PHI may only be disclosed to a person who has written permission from the applicant, member, legally authorized representative (LAR) or authorized representative (AR) to obtain the information. The applicant, member, LAR or AR authorizes the release of information by completing and signing:

Note: If the case information to be released includes PHI, the document must also tell the applicant, member, LAR or AR that information released under the document may no longer be private, and may be released further by the person receiving the information.

Occasionally, requests for information from the case records of deceased members are received. In these instances, protect the confidentiality of the former members and their survivors.

The HHSC Privacy Office handles questions about the release of information. All questions and problems encountered by individuals concerning release of information should be referred to this office. MCO staff should contact HHSC Managed Care Compliance & Operations (MCCO) staff.

 

1616 Verification and Documentation of Disclosure

Revision 18-0; Effective September 4, 2018
 
It is only acceptable for Program Support Unit (PSU) staff to disclose protected health information (PHI) to the applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party individual to whom the applicant, member, LAR or AR has provided written consent for the release of PHI.

PSU staff verify the identity of the person who requests disclosure of PHI by examining two forms of identification, with at least one form of identification being a government-issued photo identification (ID):

When disclosing PHI, PSU staff must document transactions and maintain documentation in the member’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record pertaining to how the identity of the person was verified and the method of how the information was released to the individual. Approved methods of releasing PHI include providing the requestor copies of documentation in person, by facsimile or by regular mail.

 

1620 Alternate Means of Communication with the Applicant or Member

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant, member, legally authorized representative (LAR) or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member, LAR or AR must specify in writing the alternate mailing address or means of contact, and include a statement that using the home mailing address or normal means of contact could endanger the applicant or member.

 

1630 Confidential Information on Notifications

Revision 18-0; Effective September 4, 2018
 
The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member, legally authorized representative (LAR) or authorized representative (AR) during the eligibility determination process. This includes inclusion of PHI by HHSC staff to third parties who receive a copy of a notification of eligibility form.

HHSC staff must not include PHI on the eligibility notice shared with the service provider or another third party.

Examples:

In the examples above, revealing specifics of the applicant or member’s income or the condition of his home environment is a violation of his or her right to confidentiality. In all cases, HHSC staff must assess any information provided by the applicant or member to determine if its release would be a confidentiality violation.

 

1631 Program Support Unit Communications with Managed Care Organizations

Revision 18-0; Effective September 4, 2018
 
In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for a member’s protected health information (PHI) to be shared only with his or her selected managed care organization (MCO). This makes it crucial that when documents containing member information are posted in the incorrect MCO folder in TxMedCentral, it be corrected immediately upon realization an error was made.

Program Support Unit (PSU) staff must send notification of all TxMedCentral posting errors to PSU Operations staff, including the document identifying information, the name of the folder in which it was erroneously posted, the name of the folder into which it should have been posted, and the time the correction was made.

Example: Posted XX_2067_123456789_ABCD_IM_MFP.doc in SUPSKW at 8:54 a.m. on December 20. Should have been posted to MOLSKW. Corrected at 9:22 a.m. December 20.

 

1640 Applicant or Member Correction of Information

Revision 18-0; Effective September 4, 2018
 
An applicant, member, legally authorized representative (LAR) or authorized representative (AR) has a right to correct any information that the Texas Health and Human Services Commission (HHSC) has about the applicant or member and any other individual on the applicant or member’s case.

A request for correction must be in writing and:

If HHSC agrees to change protected health information (PHI), the corrected information is added to the case record, but the incorrect information remains in the file with a note that the information was amended per the member’s request.

Notify the member, LAR or AR in writing within 60 days (using current agency letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC or the MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC or the MCO makes a correction to PHI, HHSC or the MCO must ask the member for permission before sharing with third parties. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if those persons may have relied or could rely on it to the disadvantage of the member. HHSC staff must follow regional procedures to contact the HHSC Office of Chief Counsel for a record of disclosures. MCOs must follow HHSC procedures as stated in the STAR Kids Managed Care Contract.

Note: Do not follow above procedures when the accuracy of information provided by a member, LAR or AR is determined by another review process, such as a:

The decision in the above review processes is the decision on the request to correct information.

 

1650 Disposal of Records

Revision 18-0; Effective September 4, 2018

To dispose of documents with member-specific information, Texas Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data, as described in the Health and Human Services (HHS) Computer Usage and Information Security Training.

 

1700 Member Rights and Responsibilities

Revision 18-0; Effective September 4, 2018
 
Member rights and responsibilities are included in the Member Handbook. The required critical elements can be found at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) at application. This document is shared in the language preference expressed by the applicant or member.

In addition, an applicant, member, LAR or AR may refer to the Title 1 Texas Administrative Code (TAC) §353 Subchapter C, Member Bill of Rights and Responsibilities, to view the full list of member rights and responsibilities.

 

1800 Notifications

Revision 18-0; Effective September 4, 2018
 

 

1810 Program Support Unit Staff Notification Requirements

Revision 18-0; Effective September 4, 2018
 
Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member, legally authorized representative (LAR) or authorized representative (AR) advising of actions taken regarding services and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member, LAR or AR of the actions taken regarding Medically Dependent Children Program (MDCP) services. Form H2065-D must be completed in plain language that can be understood by the applicant, member, LAR or AR. The language preference of the applicant, member, LAR or AR must be considered.

The applicant, member, LAR or AR must be notified on Form H2065-D within two business days of the date a case is certified for MDCP. Form H2065-D also includes information on the individual’s room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant who is denied program eligibility or a member whose program eligibility is terminated. PSU staff must notify the applicant, member, LAR or AR using Form H2065-D of the denial of application within two business days of the decision. Refer to Section 6000, Denials and Terminations.

Depending on when the notification is generated, Form H2065-D will either be posted to the MCO STAR Kids folder in TxMedCentral or generated in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal on the case action date.

 

1820 Managed Care Organization Notification Requirements

Revision 18-0; Effective September 4, 2018
 
The managed care organization (MCO) is responsible for notifying the member, legally authorized representative (LAR) or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member, LAR or AR has a right to appeal. Appeal rights of STAR Kids members are in the STAR Kids Managed Care Contract.
 

1830 Notifications with Medicaid for the Elderly and People with Disabilities or Texas Works Involvement

Revision 18-0; Effective September 4, 2018
 
Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Program Support Unit (PSU) staff must coordinate changes, approvals, and denials of Medically Dependent Children Program (MDCP) services with the MEPD specialist.

Although the MEPD specialist is required to notify the applicant, member, legally authorized representative (LAR) or authorized representative (AR) of all Medicaid eligibility decisions, PSU staff are required to mail the MDCP applicant, member, LAR or AR the notification of denial of MDCP services on Form H2065-D, Notification of Managed Care Program Services. PSU staff also fax the MEPD specialist a copy of Form H2065-D at initial certification and denial for case actions that involve Medicaid eligibility. PSU staff communications with MEPD that do not include Form H2065-D must include Form H1746-A, MEPD Referral Cover Sheet. MEPD specialists communicate with PSU staff through the MEPD Communication Tool.