1000, STAR Kids Overview and Eligibility

Revision 21-10; Effective October 25, 2021

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:

  • identification of needs, including physical health, behavioral health services and LTSS development of an individual service plan (ISP) to address those identified needs;
  • assistance to ensure timely and coordinated access to an array of providers and services;
  • attention to addressing unique needs of members; and
  • coordination of Medicaid benefits with non-Medicaid services and supports, as necessary and appropriate.

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

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:

  • coordinate care across service arrays;
  • improve quality, continuity and customization of care;
  • improve access to care and provide person-centered health homes;
  • improve ease of program participation for members, managed care organizations (MCOs) and providers;
  • improve provider collaboration and integration of different services;
  • improve member outcomes to the greatest extent achievable;
  • prepare young adults for the transition to adulthood;
  • foster program innovation; and
  • achieve cost efficiency and cost containment.

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:

  • enabling children and young adults who are medically dependent to remain safely in their homes;
  • offering cost-effective alternatives to placement in NFs and hospitals; and
  • supporting families in the role as the primary caregiver for their children and young adults who are medically dependent.

1200, Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022

An individual applicant or member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

  • be birth through 20;
  • live in Texas;
  • have an approved medical necessity (MN) for a nursing facility (NF) level of care (LOC);
  • have a need for at least one MDCP service not being addressed by other existing services and supports;
  • not be enrolled in another waiver program;
  • live in an appropriate living situation;
  • have a STAR Kids individual service plan (SK-ISP) with services under the established cost limit; and
  • have full Medicaid eligibility.

Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an individual, applicant or member.

1200.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 22-3; Effective Sept. 9, 2022 

An individual, applicant or member must meet the following criteria as stated in Title 1 Texas Administrative Code (TAC) Section 353.1155 to be eligible for the Medically Dependent Children Program (MDCP):

  • be under 21 years old; 
  • reside in Texas; 
  • meet the level of care criteria (LOC) for medical necessity (MN) for nursing facility (NF) care as determined by the Texas Health and Human Services Commission (HHSC); 
  • have an unmet need for support in the community that can be met through one or more MDCP services; 
  • choose MDCP as an alternative to NF services, as described in 42 Code of Federal Regulations (CFR) Section 441.302(d)
  • not be enrolled in one of the following Medicaid Home and Community Based Services (HCBS) waiver programs approved by the Centers for Medicaid & Medicare Services (CMS): 
    • the Community Living Assistance and Support Services (CLASS) Program; 
    • the Deaf Blind with Multiple Disabilities (DBMD) Program; 
    • the Home and Community-based Services (HCS) Program; 
    • the Texas Home Living (TxHmL) Program; or 
    • the Youth Empowerment Services waiver; 
  • live in: 
  • be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title (relating to Medicaid Eligibility for the Elderly and People with Disabilities).

An applicant receiving NF Medicaid will be approved for MDCP if the applicant:

  • requests services while residing in a NF; and 
  • meets the eligibility criteria listed above.

1210 Medical Necessity Determination

Revision 23-4; Effective Aug. 21, 2023

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) to meet MDCP eligibility criteria. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI).

The managed care organization (MCO) completes and submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care Online Portal (LTCOP). The TMHP nurse or physician processes the SK-SAI and determines the applicant’s or member’s Resource Utilization Group (RUG) value and MN. The MCO uses the SK-SAI to create the applicant or member’s STAR Kids individual service plan (SK-ISP). The SK-ISP lists the applicant or member’s services and preferences for care. The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the RUG value.

Program Support Unit (PSU) staff do not calculate the SK-ISP cost limit. TMHP LTCOP automatically calculates the cost limit based on the RUG value. PSU staff must verify the applicant or member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than the Annual Cost Limit in the TMHP LTCOP SK-ISP.

PSU staff must upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions. PSU staff must document all actions and verifications in the HEART case record.
 

1210.1 Texas Administrative Code Medical Necessity Determination Requirements

Revision 22-3; Effective Sept. 9, 2022 

Medical necessity (MN) is the prerequisite for participation in the Medically Dependent Children Program (MDCP). An individual, applicant or member must meet the following criteria as stated in Title 26 of the Texas Administrative Code at Section 554.2401 to meet the MN criteria for participation in MDCP. MN exists when an individual, applicant or member meets the conditions described below:

  • The person must demonstrate a medical condition that: 
    • is sufficiently serious that the person's needs exceed the routine care which may be given by an untrained person; and 
    • requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution. 
  • The person must require medical or nursing services that: 
    • are ordered by a physician; 
    • are dependent upon the person's documented medical conditions; 
    • require the skills of a registered or licensed vocational nurse; 
    • are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and 
    • are required on a regular basis.

1210.2 Medical Necessity Approval Time Frame for Initial Eligibility Determinations

Revision 23-4; Effective Aug. 21, 2023

A medical necessity (MN) approval is valid for 120 days from the Texas Medicaid & Healthcare Partnership (TMHP) MN approval date for an initial applicant. The managed care organization (MCO) must complete a new initial STAR Kids Screening and Assessment Instrument (SK-SAI) if the applicant is not enrolled in the Medicaid for Dependent Children Program (MDCP) within 120 days from the MN approval. Refer to Section, 2002.2 Medical Necessity Approval Time Frame for Initial Eligibility Determinations, for more information.

1220 Individual Cost Limit

Revision 23-3; Effective May 22, 2023

A Medically Dependent Children Program (MDCP) applicant or member’s STAR Kids individual service plan (SK-ISP) must fall within the applicant or member’s cost limit. The managed care organization (MCO) conducts a STAR Kids Screening and Assessment Instrument (SK-SAI) to assess the applicant or member. The Texas Medicaid & Healthcare Partnership (TMHP) processes the SK-SAI and determines the applicant or member’s Resource Utilization Group (RUG) value and medical necessity (MN) for MDCP. The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the RUG value.

Program Support Unit (PSU) staff must not calculate the SK-ISP cost limit as it is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field.

PSU staff must refer to 1 Texas Administrative Code (TAC) Section 353.1155, and the STAR Kids Handbook (SKH) for more information about the MDCP cost limit.

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 HandbookChapter 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 23-3; Effective May 22, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1155 states that an individual, applicant or member must be financially eligible for Medicaid toss receive the Medically Dependent Children Program (MDCP).

Program Support Unit (PSU) staff reviews Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

An MDCP individual who is not already Medicaid eligible must complete Form H1200, Application for Assistance  – Your Texas Benefits, to be evaluated for Medicaid financial eligibility. PSU staff fax the completed Form H1200 to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days from receipt of the application. The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, and Form H1200 to the individual within two business days from: 

  • the 30th day of the mail date of the application, if the individual has not returned Form H1200; or
  • upon receipt of an unsigned Form H1200. 

PSU staff denies the individual within two business days from the 30th day of the date Form 2606 was mailed if the individual did not return the signed and completed Form H1200. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual.

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:

  • ambulance services;
  • audiology services, including hearing aids;
  • behavioral health services, including:
    • in-patient mental health services;
    • out-patient mental health services;
    • out-patient chemical dependency services for children;
    • detoxification services; and
    • psychiatry services;
  • birthing services provided by a certified nurse midwife in a birthing center;
  • chiropractic services;
  • dialysis;
  • durable medical equipment (DME) and supplies;
  • emergency services;
  • family planning services;
  • home health care services;
  • inpatient hospital services;
  • outpatient hospital services;
  • laboratory;
  • medical checkups and Comprehensive Care Program (CCP) services for children and young adults through the Texas Health Steps Program (THSteps);
  • oral evaluation and fluoride varnish in conjunction with THSteps medical checkup for children six months through 35 months of age;
  • optometry, glasses and contact lenses, if medically necessary;
  • podiatry;
  • prenatal care;
  • primary care services;
  • radiology, imaging and X-rays;
  • specialty physician services;
  • therapies, including physical, occupational and speech;
  • transplantation of organs and tissues; and
  • vision services.

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):

  • Day Activity and Health Services (DAHS) for members age 18 through 20. DAHS includes nursing and Personal Care Services (PCS), therapy extension services, nutrition services, transportation services and other supportive services.
  • PCS will provide assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.
  • Prescribed pediatric extended care center (PPECC), which is a facility that provides nonresidential basic services, including medical, nursing, psychosocial, therapeutic, and developmental services to medically dependent or technologically dependent members under the age of 21 up to 12 hours per day.
  • Private duty nursing (PDN) is nursing services for members who meet medical necessity (MN) criteria outlined in the SK-SAI and who require individualized, continuous skilled care beyond the level of skilled nursing visits provided under Texas Medicaid home health services.

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:

  • Community First Choice (CFC), which is available to all STAR Kids members who meet an institutional LOC for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease. Members enrolled in a §1915(c) Medicaid waiver program for individuals with an intellectual disability or related condition (IID) receive CFC through their waiver provider. CFC services include:
    • Habilitation, also called CFC-HAB, which provides acquisition, maintenance and enhancement of skills necessary for the member to accomplish ADLs, IADLs and health-related tasks.
    • CFC personal assistance services (PAS), also called CFC-PAS, which provide assistance with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks. 
      Note: CFC-PAS is the same service as PCS. The key difference is CFC-PAS is part of the CFC benefit and must be reported differently. Members may choose to receive CFC-PAS only if he or she does not need or want CFC habilitation.
    • Emergency Response Services (ERS), which is back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports.
    • Support management, which is training provided to members, legally authorized representatives (LARs) or authorized representative (ARs) on how to manage and dismiss their attendants.

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:

  • Adaptive aids, which are needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps a member perform the ADL or control the environment in which he or she lives. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources (TPR).
  • Employment assistance (EA), which is assistance provided to a member to help the member locate paid, competitive employment in the community.
  • Financial management services (FMS) for members who choose the Consumer Directed Services (CDS) option. FMS provides assistance to members with managing funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.
  • Flexible Family Support Services (FFSS) are direct care services needed because of a member’s disability that help a member participate in child care, post-secondary education, employment, independent living or support a member’s move to an independent living situation.
  • Minor home modifications are physical changes to a member’s residence that are needed to prevent institutionalization or to support the most integrated setting for a member to remain in the community.
  • Respite services are direct care services needed because of a member’s disability that provides a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
  • Supported employment (SE) provides assistance to sustain paid, competitive employment to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which members without disabilities are employed.
  • Transition Assistance Services (TAS) are a one-time service provided to a Medicaid-eligible resident of an NF located in Texas to assist the resident in moving from the NF into the community to receive MDCP services.

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:

  • Community First Choice habilitation (CFC-HAB);
  • Community First Choice personal assistance services (CFC-PAS); and
  • Personal Care Services (PCS).

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

  • employment assistance (EA);
  • Flexible Family Support Services (FFSS);
  • respite; and
  • supported employment (SE).

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:

  • review the member’s current short-term and long-term goals and objectives, as documented in the ISP;
  • acknowledge and document goals and objectives the member has achieved or with which the member has made progress;
  • acknowledge and document goals and objectives that may need to be adjusted;
  • develop new goals and objectives with input from the member, family, LAR, AR and providers;
  • update the member’s ISP;
  • assist with development and management of the ISP and budget for members receiving Medically Dependent Children Program (MDCP) services;
  • inform members receiving long term services and supports (LTSS) about the Consumer Directed Services (CDS) and Service Responsibility Option (SRO);
  • educate the member, LAR or AR about their rights regarding acts that constitute abuse or neglect (Child Protective Services) and abuse, neglect or exploitation (Adult Protective Services (APS)); and
  • review member rights and MCO processes for service authorization, appeals and complaints.

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:

  • are enrolled in the Medically Dependent Children Program (MDCP) or Youth Empowerment Services (YES) waiver program;
  • have complex needs or a history of developmental or behavioral health issues (multiple outpatient visits, hospitalization or institutionalization within the past year);
  • are diagnosed with severe emotional disturbance (SED) or serious and persistent mental illness (SPMI); or
  • are at risk for institutionalization.

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:

  • do not meet the requirements for Level 1 but receive long term services and supports (LTSS);
  • the MCO believes would benefit from a higher level of service coordination based on results from the STAR Kids Screening and Assessment Instrument (SK-SAI) and additional MCO findings;
  • have a history of substance abuse (multiple outpatient visits, hospitalization or institutionalization within the past year); or
  • are without SED or SPMI, but who have another behavioral health condition that significantly impairs function.

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:

  • name of the service coordinator;
  • telephone number of the service coordinator;
  • minimum number of contacts he or she will receive every year; and
  • types of contacts he or she will receive.

1420 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

1430 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

1440 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

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:

  • ensuring MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
  • responding within three business days to concerns from the Texas Health and Human Services Commission (HHSC) or recovery managers (RMs) to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the HCBS-AMH program.

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:

  • Send requested information to the RM or HHSC three business days prior to the scheduled recovery plan meeting. This information includes:
    • updating the member’s condition;
    • sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
    • upcoming MCO service coordinator face-to-face appointments and/or scheduled dates for telephonic contacts with the member; and
    • relevant member treatment documents as requested by the RM or HHSC.
  • Respond to ad-hoc requests from the RM or HHSC with "Urgent" in the subject line within one business day.
  • Respond to non-urgent ad-hoc requests in a timely manner.
  • Coordinate with HHSC and the RM when a member transitions into or out of HCBS-AMH.

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.

1500, Reserved for Future Use

1600, Disclosure of Information

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:

  • past, present or future physical, mental or behavioral health or condition of the applicant or member;
  • provision of health care to the applicant or member; or
  • past, present or future payment for the provision of health care to the applicant or member.

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:

  • in a locked office when the building is closed;
  • properly filed during office hours; and
  • in the office at all times, except when authorized to remove or transfer them.

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:

  • the minor child can consent to medical treatment. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment when the:
    • minor is on active duty with the U.S. military;
    • minor is age 16 years or older, lives separately from the parents and manages his or her own financial affairs;
    • consent involves diagnosis and treatment of disease that must be reported to the local health officer or the Texas Department of State Health Services (DSHS);
    • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
    • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by DSHS;
    • consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by the state of Texas;
    • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
    • consent involves suicide prevention or sexual, physical or emotional abuse.
  • a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about health care decisions not made by the parent.

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:

  • person the member has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
  • court-appointed guardian for the applicant or member; or
  • person designated by law to make health care decisions when the applicant or member is in a hospital or nursing facility (NF) and is incapacitated or mentally or physically incapable of communication.

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:

  • an executor, including an independent executor;
  • an administrator, including a temporary administrator;
  • a surviving spouse;
  • a child;
  • a parent; and
  • an heir.

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 Establishing Identity 

Revision 23-4; Effective Aug. 21, 2023

 

1614.1 Phone Communication

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must establish the identity of a person who self-identifies as an individual, applicant, member, legally authorized representative (LAR) or medical consenter over the phone. PSU staff must verify the person’s knowledge of two of the following about the individual, applicant or member:

  • Social Security number (SSN);
  • date of birth (DOB); or
  • Medicaid identification (ID) number.

PSU staff must verify that the person who self-identifies as a LAR or medical consenter over the phone is listed as the LAR or medical consenter in:

  • the Texas Integrated Eligibility Redesign System (TIERS); or
    • Note: The medical consenter is known as the ‘Alternate Payee’ in TIERS when the individual, applicant, or member has STAR Health or Medicaid as a result of Department of Family and Protective Services (DFPS) involvement.
  • the most recent signed Form H1200, Application for Assistance – Your Texas Benefits; or
  • Form H1826, Case Information Release, completed and signed by the individual, applicant or member.

PSU staff must not release case information to a person who is not able to be verified as the individual, applicant, member, LAR or medical consenter.

Refer to Section 1615, Information That May Be Disclosed, for more information about scenarios when: 

  • PSU staff is not able to verify the person calling;
  • the person calling PSU staff is not the individual, applicant, member, LAR or medical consenter; or
  • PSU staff must obtain Form H1826.

PSU staff must direct all case-related information requests from a lawyer to the PSU supervisor. 

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):

  • valid U.S. passport;
  • Texas Department of Public Safety (DPS) ID card;
  • DPS driver license;
  • DPS Texas Election Identification Certificate;
  • DPS handgun license;
  • U.S. military identification card containing the person’s photograph;
  • U.S. citizenship certificate containing the person’s photograph;
  • state agency employee badge;
  • Social Security number (SSN) card;
  • Medicaid ID card;
  • birth certificate or birth record;
  • hospital record;
  • work or school ID card;
  • voter registration card; and/or
  • wage stub.

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

  • employee badge; or
  • government-issued identification card with a photograph.

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

  • official correspondence or a telephone call from a state or regional office; or
  • contact the HHSC Office of Chief Counsel.

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:

  • if PSU staff can answer the inquiry without supplying PHI, remove any PHI in the original request, notify the sender that this is not a secure method of transmission for PHI, and respond to the sender appropriately; or
  • if the answer to the inquiry requires the inclusion of PHI, remove any PHI in the original request, notify the sender that this is not a secure method of transmission of PHI, and respond to the sender that he or she must submit their request in writing via mail or facsimile.

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:

  • is sent to a verified email address;
  • is sent as an encrypted message;
  • does not contain PHI in the email’s subject line; and
  • contains this disclaimer: "Confidential: This transmission is confidential and intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient, you are notified that any review, retention, disclosure, copying, distribution, or the taking of any other action relevant to the contents of this transmission are strictly prohibited. If you received this transmission in error please return to sender."

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 23-4; Effective Aug. 21, 2023

The Texas Health and Human Services Commission (HHSC) follows Title 20 Code of Federal Regulations (CFR) Sections 401-403 concerning the disclosure of information about: 

  • a person, both with and without the person's consent; 
  • the maintenance of records; and
  • the general guidelines in deciding whether to make a disclosure.

Program Support Unit (PSU) staff must make reasonable efforts to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to:

  • determine eligibility;
  • operate the program; and
  • accomplish the request for disclosure.

PSU staff must only disclose case-related information with a person verified by the methods described in Section 1614.1, Phone Communication, Section 1614.2, In-Person Communication, and Section 1614.3, Electronic Mail Communication, when:

  • the Texas Integrated Eligibility Redesign System (TIERS) indicates that the person requesting the information is the legally authorized representative (LAR);
  • the person is the medical consenter as indicated in TIERS; 
    • The medical consenter is known as the ‘Alternate Payee’ in TIERS when the individual, applicant, or member has STAR Health or Medicaid as a result of Department of Family and Protective Services (DFPS) involvement.
  • a signed Form H1200, Application for Assistance – Your Texas Benefits, indicates the person requesting the information is the LAR or medical consenter;
  • a valid Form H1826, Case Information Release, is on file or received;
  • the person is HHSC staff including the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; or
  • the person is an HHSC contractor such as the managed care organization (MCO) or the Texas Medicaid & Healthcare Partnership (TMHP) staff.

PSU staff must refer requests to disclose information from federal agency staff, research staff or lawyer to the PSU supervisor.

PSU staff must complete the following activities when a person requesting the information does not fit in the categories noted in the previous paragraphs:

  • research the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record for Form H1826;
  • verify the individual, applicant, member, LAR or medical consenter signed Form H1826;
  • ensure the person only receives the information approved for release on Form H1826; and 
  • ensure Form H1826 is not expired.

PSU staff may use the following: 

  • an existing and valid Form H1826 found in the HEART case record; or 
  • a newly submitted Form H1826 received from the individual, applicant, member, LAR or medical consenter.

A valid Form H1826 is:

  • signed by the individual, applicant, member, LAR or medical consenter; and
  • within the information release authorization time frame.

PSU staff must ask the person requesting the information to provide a new Form H1826 if an existing Form H1826:

  • is not signed;
  • is expired; or 
  • does not authorize the release of the information requested.

PSU staff must complete the following activities within two business days of receiving a valid Form H1826:

  • create a HEART case record, if applicable;
  • upload Form H1826 to the HEART case record;
  • contact the person approved by the individual, applicant, member, LAR or medical consenter, as applicable, to receive case information;
  • provide only the specific case information noted on Form H1826 during the approved time frame specified on Form H1826; and
  • document the HEART case record.

The Office of the Chief Counsel at HHSC manages questions and concerns about releasing information. PSU staff must refer an individual, applicant, member, LAR or medical consenter to the Office of the Chief Counsel if there are questions and problems concerning releasing information.

PSU staff must notify the PSU supervisor if a person requests copies of an individual, applicant, or member’s records maintained by the HHSC.

PSU staff may refer to Title 20 CFR Sections 401-403, for more information regarding the disclosure of PHI.

PSU staff may refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements regarding STAR Health individuals, applicants, members or medical consenters.
 

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):

  • Valid U.S. passport;
  • Texas Department of Public Safety (DPS) ID card;
  • DPS driver license;
  • DPS Texas Election Identification Certificate;
  • DPS handgun license;
  • U.S. military identification card containing the person’s photograph;
  • U.S. citizenship certificate containing the person’s photograph;
  • work or school identification card;
  • state agency employee badge;
  • Social Security number (SSN) card;
  • Medicaid ID card;
  • birth certificate or birth record;
  • hospital record;
  • work or school ID card;
  • voter registration card; and/or
  • wage stub.

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:

  • Notification is received from Medicaid for the Elderly and People with Disabilities (MEPD) that the member has lost Medicaid because his income of $2,892 exceeds the eligibility limit of $2,022. It is a violation of confidentiality to record on Form H2065-D, Notification of Managed Care Program Services, "Your income of $2,892 exceeds the eligibility limit of $2,022." The comment should simply state, "You are no longer eligible for Medicaid."
  • Another applicant is being denied Medically Dependent Children Program (MDCP) services because the presence of weapons in his or her home presents a hazard to service providers. It is a violation of confidentiality to record on Form H2065-D, "The presence of weapons in your home presents a hazard to service providers." The comment should simply state, "Your services are being denied due to hazardous conditions in your home."

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:

  • identify the applicant or member asking for the correction;
  • identify the disputed information about the applicant or member;
  • state why the information is wrong;
  • include any proof that shows the information is wrong;
  • state what correction is requested; and
  • include a return address, telephone number or email address at which HHSC can contact the applicant or member.

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:

  • fair hearing;
  • civil rights hearing; or
  • other appeal process.

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

1810 Program Support Unit Staff Notification Requirements

Revision 23-4; Effective Aug. 21, 2023

Form H2065-D, Notification of Managed Care Program Services, is the legal notice Program Support Unit (PSU) staff must mail to the applicant, member, legally authorized representative (LAR) or medical consenter indicating:

  • the Medically Dependent Children Program (MDCP) eligibility for approvals, denials and terminations for MDCP; 
  • the right to a state fair hearing, as applicable;
  • annual cost-of-living adjustments (COLA) for room and board (R&B) charges; and
  • a fair hearing officer’s ruling to reverse an MDCP denial or termination.

PSU staff must mail the English and Spanish versions of Form H2065-D to the applicant, member, LAR or medical consenter.

PSU staff generate Form H2065-D manually or electronically through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) as applicable. PSU staff must follow the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, when completing Form H2065-D.

PSU staff must notify the applicant, member, LAR or medical consenter of MDCP approval using Form H2065-D upon verification that the applicant or member meets all eligibility criteria. PSU staff time frames for mailing Form H2065-D vary depending on the approval type. For example, PSU staff must mail Form H2065-D for an approval within: 

  • 24 hours of the nursing facility (NF) discharge for the Money Follows the Person (MFP) limited NF stay process;
    • Note: The applicant must meet all MDCP, and MFP limited NF stay eligibility criteria before admission to the NF for the limited NF stay.
  • One business day from the date the applicant meets all MDCP eligibility criteria for the first Form H2065-D used in the Traditional MFP process;
  • five business days from the date of NF discharge for the second Form H2065-D used in the Traditional MFP process;
    • Note: The applicant must meet all MDCP and MFP eligibility criteria before discharging from the NF.
  • two business days from the date the member meets all MDCP eligibility criteria for interest list releases (ILRs); and
  • five business days from the date the member is determined to continue to meet all MDCP eligibility criteria for reassessments.

PSU staff must notify the applicant, member, LAR or medical consenter of a program eligibility denial or termination using Form H2065-D upon notification that eligibility criteria is not being met within two business days.

PSU staff must provide the English version of Form H2065-D to the managed care organization (MCO) either: 

  • electronically through the TMHP LTCOP; or
  • manually by uploading to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, as applicable. 
     

1820 Managed Care Organization Notification Requirements for PSU Staff

Revision 21-10; Effective October 25, 2021

The managed care organization (MCO) must use Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, and Form H2067-MC, Managed Care Programs Communication, for all communications sent to Program Support Unit (PSU) staff, as applicable. The MCO must upload Form H3676, Section B, or Form H2067-MC to TxMedCentral. PSU staff will retrieve all MCO postings daily from TxMedCentral.

The MCO has 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral, to upload Form H3676, Section B, for individuals or applicants. The MCO has between one business day and 14 days to upload Form H2067-MC, depending on the situation for an individual, applicant or member. Specific MCO time frames for Form H2067-MC are defined throughout this handbook.

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.