STAR Kids Program Support Unit Operational Procedures Handbook

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.

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.

2000, Medically Dependent Children Program Intake and Initial Application

2001 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.

2001.1 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. 

2002 Medical Necessity Determination

Revision 23-4; Effective Aug. 21, 2023 

A Medically Dependent Children Program (MDCP) applicant 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 Resource Utilization Group (RUG) value and MN. The MCO uses the SK-SAI to create the applicant’s STAR Kids individual service plan (SK-ISP). The SK-ISP lists the applicant’s services and preferences for care. The cost of the applicant’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’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.
 

2002.1 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). MN exists when an individual, applicant or member meets the conditions described below:

  • The individual must demonstrate a medical condition that: 
    • is of sufficient seriousness that the individual’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 individual must require medical or nursing services that: 
    • are ordered by a physician; 
    • are dependent upon the individual’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.

2002.2 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.

Program Support unit (PSU) staff must complete the following activities within two business days from the MN expiration of 120 days:

  • upload Form H2067-MC,  Managed Care Programs Communication, to TxMedCentral advising the MCO:
    • the approved MN determination is past 120 days; and
    • a new initial SK-SAI is required for PSU staff to determine MDCP eligibility;
  • upload Form H2067-MC to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document the HEART case record.

The MCO must submit a new initial SK-SAI to the TMHP Long Term Care Online Portal (LTCOP) before PSU staff can determine MDCP eligibility. 
 

2010 Initial Requests for Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list, regardless of the program’s enrollment status, according to the date and time of the request. Individuals are released from the MDCP interest list in the order of their request date. An individual is placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual’s name may only be added to the MDCP interest list if the individual is less than age 21 and resides in Texas.

2020 Interest List Management Unit Responsibilities

Revision 21-10; Effective October 25, 2021
 
Interest List Management (ILM) Unit staff are Texas Health and Human Services Commission (HHSC) staff responsible for maintaining and releasing individuals from the Medically Dependent Children Program (MDCP) interest list. ILM Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the MDCP program. ILM Unit staff must release individuals from the MDCP program interest list as slots become available in the program.

ILM Unit staff perform the following activities for individuals who request placement on the MDCP interest list:

  • Place individuals on the interest list;
  • Maintain annual contact requirements;
  • Release individuals from the interest list when funding is available; and
  • Confirm individuals on the interest list are viable MDCP candidates before release by:
    • verifying all contact information is correct;
    • checking the Texas Integrated Eligibility Redesign System (TIERS) to determine the Medicaid eligibility status;
    • confirming Texas residency; and
    • verifying the individual is still interested in the MDCP.

ILM Unit staff are required to complete annual contacts for individuals on the MDCP interest list to verify the current address, phone number and confirm continued interest in the program. The interest list status will automatically update to an inactive status if no response is received from the individual within 120 days of the annual contact. The individual will remain in an inactive status until the individual notifies ILM Unit staff of continued interest in MDCP.

ILM Unit staff perform the following activities upon an individual’s release from the MDCP interest list:

  • Verify the individual’s Medicaid type of assistance (TOA) in TIERS, if applicable;
  • Contact the individual by phone to notify them of reaching the top of the interest list;
  • Confirm continued interest in MDCP;
  • Provide a general description of MDCP services;
  • Discuss managed care organizations (MCOs) operating in the individual’s service area (SA);
  • Encourage the individual to contact the MCO for additional information and available services, if applicable;
  • Create a Program Support Unit (PSU) MDCP interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Assign each MDCP ILR HEART case record to PSU staff for individuals who confirm interest in MDCP; and
  • Update the CSIL database record’s status to assigned.

If the individual does not wish to pursue MDCP:

  • The individual can be added back to the bottom of the interest list for an offer in the future, at the individual’s request; or
  • The ILR will be closed with the appropriate closure code in the CSIL database.

See the Uniform Managed Care Manual (UMCM) §16.2 for specific requirements regarding MDCP interest list releases for STAR Health members.

PSU staff must refer to Section 2100, Enrollment Following Release from the Interest List, for MDCP procedures following an individual’s release from the MDCP interest list.

An individual requesting MDCP through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the ILM Unit or their MCO. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in bypassing the interest list through the MFP limited stay option.

PSU staff must refer to Section 2400, Money Follows the Person, for ILM procedures related to MFP processes.

2030 Program Support Unit Staff Responsibilities

Revision 18-0; Effective September 4, 2018

The Program Support Unit (PSU) staff are regional Texas Health and Human Services Commission (HHSC) staff responsible for facilitating the required components of the Medically Dependent Children Program (MDCP) eligibility process by coordinating between HHSC, managed care organizations (MCOs) and MDCP individuals. PSU staff document all coordination efforts in the individual’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

2100, Enrollment Following Release from the Interest List

Revision 21-10; Effective October 25, 2021

Interest List Management (ILM) Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the Medically Dependent Children Program (MDCP). ILM Unit staff must release individuals from the MDCP interest list as slots become available in the program.

ILM Unit staff contact all individuals by phone to notify them of their names reaching the top of the list and to confirm interest in applying for MDCP. ILM Unit staff will create an interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) and assign it to Program Support Unit (PSU) staff when the individual confirms their interest to pursue MDCP.

2100.1 Individual  Not Enrolled in Medicaid, Including an Individual Enrolled in the Children’s Health Insurance Program  

Revision 21-10; October 25, 2021

An individual who does not receive Medicaid and is not enrolled in a managed care organization (MCO) must go through the process of MCO selection, medical necessity (MN) assessment, and financial eligibility determination including individuals enrolled in the Children’s Health Insurance Program (CHIP).

Program Support Unit (PSU) staff must complete the following activities within three business days of the receipt of the Medically Dependent Children Program (MDCP) interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waivers programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):

PSU staff are responsible for completing the below activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or LAR, and any delays in the HEART case record. PSU staff must contact the individual or LAR to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Explain the Medicaid application process;
  • Give a general description of MDCP services;
  • Explain the need to select an MCO as quickly as possible within 14 days from the mail date of the above enrollment packet;
  • Inform the individual or LAR that any delay in selecting an MCO could result in a delay in an eligibility determination for MDCP;
  • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible;
  • Advise the individual or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS; and
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, and Form H1200 to the Medicaid for Elderly and People with Disabilities (MEPD) specialist within two business days of the receipt of a completed Form H1200 for medical assistance only (MAO) applicants.

PSU staff must indicate on Form H1746-A that this is a financial eligibility request for an MDCP applicant.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO of the ILR closure;
  • Close the ILR in the Community Services Interest List (CSIL) database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain an MCO selection if PSU staff have not received the MCO selection;
  • Obtain confirmed interest in MDCP if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual:
    • does not select an MCO;
    • does not express interest in MDCP; or
    • has not provided Form H1200; and
  • Advise the individual or LAR to immediately submit Form H1200, if PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

The individual, applicant or LAR must select an MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection or interest in MDCP.

PSU staff must assign an MCO based on criteria developed by HHSC from the list of available MCOs in the individual’s or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must refer to Section 2210.1, Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program, when PSU staff receive:

  • Confirmed interest in MDCP; and
  • An MCO selection.

2100.2 Individual Who Receives Supplemental Security Income or SSI-Related Medicaid

Revision 21-10; Effective October 25, 2021

An individual with Supplemental Security Income (SSI) or SSI-related Medicaid is already enrolled with a STAR Kids managed care organization (MCO) and does not need to go through the process of selecting a STAR Kids MCO or financial eligibility determination. The individual must receive a medical necessity (MN) assessment.

Program Support Unit (PSU) staff must complete the following activities within three business days of the receipt of the Medically Dependent Children Program (MDCP) interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or the Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind and Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
    • Form 2600-B, MDCP Waiver Release Letter - Supplemental Security Income;
    • Form 2602, Application Acknowledgement;
    • Appendix IV, MDCP Frequently Asked Questions;
    • Appendix XX, MDCP Program Description; and
    • a postage-paid envelope.

PSU staff are responsible for completing the below activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or LAR and any delays in the HEART case record. PSU staff must contact the individual or LAR:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Give a general description of MDCP services; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual or LAR has not expressed interest in MDCP.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual does not express interest in MDCP.

PSU must document all contact attempts in the HEART case record.

The individual or LAR is not required to select an MCO since the individual is already enrolled with a STAR Kids MCO. PSU staff can accept the individual or LAR’s verbal statement of interest in MDCP.

2100.3 Individual Who Receives STAR Health

Revision 18-0; Effective September 4, 2018

See the Uniform Managed Care Manual (UMCM) for STAR Health members.

The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.

An individual enrolled with a STAR Health managed care organization (MCO) must remain enrolled with the STAR Health MCO.

If the medical consenter chooses to decline MDCP services, refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements.

2100.4 Individual Who Receives Other Types of Medicaid

Revision 21-10; Effective October 25, 2021

An individual who receives other types of Medicaid, i.e., non-Supplemental Security Income (SSI) or is enrolled with a STAR managed care organization (MCO), must go through the process of selecting a STAR Kids MCO, medical necessity (MN) assessment and a financial eligibility determination, if applicable.

Program Support Unit (PSU) staff must refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for Medically Dependent Children Program (MDCP).

PSU staff must complete the following activities within three business days of the receipt of the MDCP interest list release (ILR) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and determine if Form H1200 and Form H1746-A are required;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind and Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waivers programs and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to individuals who do not require Form H1200:
  • Mail the following enrollment packet to individuals who require Form H1200:
    • Form 2600-A, MDCP Waiver Release Letter – Medicaid Assistance Only;
    • Form 2602;
    • Form H2053-B;
    • Form H1200;
    • STAR Kids Comparison Charts;
    • STAR Kids Report Cards;
    • Appendix IV;
    • Appendix XX; and
    • a postage-paid envelope.

PSU staff are responsible for completing the below activities within 14 days of mailing the enrollment packet. PSU staff must document all attempted contacts with the individual or legally authorized representative (LAR) and any delays in the HEART case record. PSU staff must contact the individual or LAR to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Explain the Medicaid application process, if applicable;
  • Give a general description of MDCP services;
  • Explain the need to select a STAR Kids MCO as quickly as possible within 14 days from the mail date of the above enrollment packet;
  • Inform the individual or LAR that any delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP;
  • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
    • has not expressed interest in MDCP;
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual or LAR to immediately submit Form H1200, if:
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS; and
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200, if applicable.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR not have an interest in pursuing MDCP.

PSU staff must fax Form H1746-A and Form H1200 to the Medicaid for Elderly and People with Disabilities (MEPD) specialist within two business days of the receipt of a completed Form H1200, if appropriate. PSU staff must indicate on Form H1746-A that this is a financial eligibility request for an MDCP applicant.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual, if appropriate:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO of the ILR closure;
  • Close the ILR in the Community Services Interest List (CSIL) database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant, if appropriate:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; and
    • has not provided Form H1200, if applicable; and
  • Advise the individual or LAR to immediately submit Form H1200 if:
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

The individual, applicant or LAR must select a STAR Kids MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of a STAR Kids MCO selection or interest in MDCP. PSU staff must assign a STAR Kids MCO based on criteria developed by HHSC from the list of available STAR Kids MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must refer to Section 2210.4, Individual Receiving Other Types of Medicaid, when PSU staff receive:

  • Confirmed interest in MDCP; and
  • A STAR Kids MCO selection from the individual or LAR.

2110 Managed Care Organization Selection

Revision 18-0; Effective September 4, 2018

The individual has 30 days from the date the enrollment packet is mailed to complete and return the enrollment packet to Program Support Unit (PSU) staff. If the individual has expressed interest in pursuing Medically Dependent Children Program (MDCP) services, verbally or in writing, but has not selected a managed care organization (MCO) within 30 days from the date the enrollment packet was mailed, an MCO is assigned based on criteria developed by Texas Health and Human Services Commission (HHSC) from the list of available MCOs in the individual’s service area (SA).

PSU staff must contact the individual within three business days of an MCO assignment to inform the individual:

  • which MCO he or she is assigned to; and
  • the MCO in which he or she is enrolled can be changed at any time, but will not go into effect until after one full calendar month of MDCP service provision.

2120 Inability to Contact the Individual

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must make one additional attempt to contact the individual by the 30th day from the date the enrollment packet was mailed if:

  • PSU staff are unable to contact the individual by telephone within 14 days from the enrollment packet mail date; and
  • The individual has not returned the enrollment packet or expressed interest in the Medically Dependent Children Program (MDCP).

PSU staff must complete the following activities within two business days from the 30th day of the enrollment packet mail date if PSU staff have not:

  • Made contact with the individual by the 30th day from the enrollment packet mail date;
  • Received the enrollment packet; or
  • Received notification from the individual of their interest in MDCP:
    • Manually generate Form 2442, Notification of Interest List Release Closure;
    • Mail Form 2442 and Appendix XX, MDCP Program Description to the individual or legally authorized representative (LAR);
    • Close the MDCP interest list release in the Community Services Interest List (CSIL) database using the closure reason ‘Released From List/No Response to Letter’;
    • Document the closure date, reason for closure and contact attempts in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
    • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
    • Document and close the HEART case record using the appropriate closure reason.

The interest list closure date is the 31st day after the issuance date on Form 2600-A, MDCP Waiver Release Letter - Medical Assistance Only, or Form 2600-B, MDCP Waiver Release Letter - Supplemental Security Income.

PSU staff must mail a request to reopen the interest list release to the Interest List Management (ILM) Unit manager at StarPlusWaiverInterestList@hhsc.state.tx.us if the individual contacts PSU or ILM Unit staff after the interest list release closure requesting to pursue MDCP.

PSU staff must refer to Section 2310, Contacting the Interest List Management Unit to Reopen a Closed Interest List Release, for additional information about processing reopen requests.

PSU staff should not attempt to contact an individual if the Texas Health and Human Services Commission (HHSC) receives information about the individual’s death. PSU staff must not mail Form 2442 or Appendix XX to the responsible party if the interest list release was closed due to the death of the individual. The effective date of the interest list release closure is the date staff received notification of the individual’s death.

2130 Declining Medically Dependent Children Program Services

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must complete the following activities within two business days from the receipt of an individual’s completed Form 2602, Application Acknowledgement, indicating no interest in applying for Medically Dependent Children Program (MDCP) or if the individual verbally declines MDCP:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • Close the MDCP interest list release in the Community Services Interest List (CSIL) database using the appropriate closure reason;
  • Document the closure date, reason for requesting closure and how PSU staff received the individual’s request for closure (e.g., if by telephone, then document the date, caller’s name and caller’s contact information) in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record using the appropriate closure reason.

See the Uniform Managed Care Manual (UMCM) §16.2 for specific requirements regarding the denial of MDCP for STAR Health members.

2200, Receipt of Enrollment Packet

Revision 18-0; Effective September 4, 2018

When Program Support Unit (PSU) staff receive the enrollment packet from the individual, PSU staff must review it to ensure all documents are completed.

If the enrollment packet is incomplete, PSU staff must contact the individual within two business days to obtain completed documents.

If the Medicaid for the Elderly and People with Disabilities (MEPD) specialist receives an unsigned Form H1200, Application for Assistance - Your Texas Benefits, from PSU staff with Form H1746-A, MEPD Referral Cover Sheet, the MEPD specialist returns Form H1200 to PSU staff with an annotation on Form H1746-A that Form H1200 is unsigned and must be signed before the Texas Health and Human Services Commission (HHSC) can establish a file date. Therefore, PSU staff must ensure Form H1200 is signed prior to referring to the MEPD specialist.

Once PSU staff receive notice of an unsigned application from the MEPD specialist, PSU staff must contact the individual within two business days to inform the individual of the need to return a signed application for processing.

Faxing unsigned applications delays the MEPD specialist’s eligibility determination process and could adversely affect service delivery to the individual.

2210 Income and Resource Verifications for Medicaid Eligibility

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must obtain a completed Form H1200, Application for Assistance – Your Texas Benefits, for medical assistance only (MAO) individuals or applicants. PSU staff must verify if Form H1200 is required for Medically Dependent Children Program (MDCP) eligibility by checking Appendix XVI, Medicaid Program Actions.

PSU staff must complete the following for individuals and applicants who require Form H1200 to determine MDCP eligibility:

  • Inform MAO individuals or applicants of the importance of providing Form H1200 and all required documents to the Medicaid for Elderly and People with Disabilities (MEPD) specialist;
  • Explain that failure to submit the required documentation to the MEPD specialist could result in a delay or denial of their application;
  • Fax Form H1200, Form H1746-A, MEPD Referral Cover Sheet, and any additional relevant financial information obtained, including information on third-party insurance, to the MEPD specialist if received;
  • Maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in Texas Integrated Eligibility Redesign System (TIERS); and
  • Maintain a copy of page one of Form H1200 in the applicant’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

Individuals and applicants with the appropriate type of Medicaid do not require Form H1200 [e.g., individuals and applicants with Supplemental Security Income (SSI)].

PSU staff must use Form H1746-A when communicating with the MEPD specialist. PSU staff must indicate the following on Form H1746-A, as applicable:

  • The individual or applicant is requesting MDCP;
  • The applicant is pending the medical necessity (MN) determination;
  • The applicant is pending the STAR Kids Individual Service Plan (SK-ISP); or
  • The applicant has an approved MN and SK-ISP.

PSU staff must fax a second Form H1746-A noting the applicant’s start of care (SOC) for MDCP if the applicant’s MN and SK-ISP were pending when the initial Form H1746-A was sent to the MEPD specialist.

The Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination, if an MDCP individual’s or applicant’s application for SSI disability has been pending for more than 90 days. The SSI decision must be adopted upon receipt from SSA.

2210.1 Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must complete the following activities within two business days from receiving the enrollment packet or confirmed interest in the Medically Dependent Children Program (MDCP) from the individual or legally authorized representative (LAR):

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, and upload it to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • Upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document the HEART case record.

PSU staff must complete the following activities within two business days following the receipt date of the signed Form H1200, Application for Assistance - Your Texas Benefits:

  • Fax the following documents to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist:
    • Form H1200;
    • Form H1746-A, MEPD Referral Cover Sheet, requesting a financial eligibility determination for MDCP; and
    • any other verification documents provided by the individual or LAR; and
  • Record the date Form H1200 was received from the applicant and the date PSU staff faxed Form H1200 to the MEPD specialist in the HEART case record;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must check the Texas Integrated Redesign System (TIERS) to verify Medicaid eligibility.

2210.2 Individual Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

An individual who receives Supplemental Security Income (SSI) or SSI-related Medicaid meets the Medicaid financial eligibility requirement for the Medically Dependent Children Program (MDCP).

Within two business days of receiving the enrollment packet or confirmed interest from the individual, legally authorized representative (LAR) or authorized representative (AR), Program Support Unit (PSU) staff must:

  • confirm the individual continues to receive SSI or SSI-related Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • confirm the STAR Kids enrollment in TIERS;
  • complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral. For Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to age one, born to Medicaid-eligible mothers, PSU staff will be required to indicate all zeros in Item No. 3, Social Security Number (SSN), in Section A of Form H3676 if the individual does not have an established SSN; and
  • upload enrollment packet documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

2210.3 Individual Enrolled in STAR Health

Revision 18-0; Effective September 4, 2018

See the Uniform Managed Care Manual (UMCM) for STAR Health members.

2210.4 Individual Receiving Other Types of Medicaid

Revision 18-0; Effective September 4, 2018

An individual who receives other types of Medicaid (non-Supplemental Security Income (SSI) related Medicaid), may or may not meet the Medicaid financial eligibility requirement for the Medically Dependent Children Program (MDCP).

Within two business days of receiving the enrollment packet or confirmed interest from the individual, legally authorized representative (LAR) or authorized representative (AR), Program Support Unit (PSU) staff must:

  • confirm the individual continues to receive Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral, following the instructions in Appendix IX, Naming Conventions. For Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to age one, born to Medicaid-eligible mothers, PSU staff will be required to indicate all zeros in Item No. 3, Social Security Number (SSN), in Section A of Form H3676 if the individual does not have an established SSN;
  • fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist requesting the individual’s Medicaid type to be changed to Medically Dependent Children Program (MDCP) Medicaid; and
  • upload enrollment packet documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool. PSU staff must upload the MEPD specialist’s email communication in the HEART case record.

2210.5 Individual with a Qualified Income Trust

Revision 22-2; Effective Sept. 5, 2022

An individual or applicant who has a qualified income trust (QIT) may be determined eligible for the Medically Dependent Children Program (MDCP) even though their income is greater than the special institutional income limit for the program. Income diverted to the trust does not count for the purposes of determining Medicaid financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for MDCP services. An individual or applicant may be eligible for services if all other eligibility criteria are met, even if the amount they have available for copayment equals or exceeds the total cost of their STAR Kids individual service plan (SK-ISP). 

PSU staff must refer questions regarding QIT to Access and Accessibility Services (AES) by generating and faxing Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist.

2220 Managed Care Organization Coordination

Revision 18-0; Effective September 4, 2018

The STAR Kids managed care organization (MCO) has 30 days following the initial notice from Program Support Unit (PSU) staff to complete all assessments for an individual enrolled in the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, for a total of 60 days following the initial notice from PSU staff. The MCO must:

  • verify the individual meets all other eligibility criteria referenced in the STAR Kids HandbookSection 1000, Overview and Eligibility;
  • complete Section B, Waiver Assessment Report, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization;
  • complete the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items; and
  • complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and submit electronically through the TMHP LTC Online Portal. For MAO individuals, complete Form 2604 and post to TexMedCentral.

If the MCO does not submit Form 2604 within 60 days after PSU staff posted Form H3676, Section A, authorizing the MCO to begin the eligibility process, PSU staff must email Managed Care Compliance & Operations (MCCO) to notify them of the MCO delinquency.

The MCO must schedule and complete the SK-SAI, including the MDCP module and record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG, within 30 days of notice from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP, by posting to TMHP LTC Online Portal within 72 hours of completion. For the purposes of this requirement, a SK-SAI is considered "complete" when the MCO has obtained the physician’s signature on Form 2601, Physician Certification, and retains Form 2601 in the individual’s case file at the MCO.

A determination of medical necessity (MN) must be based on information collected as part of the SK-SAI and NCAM module (record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG). The MN determination must be approved by TMHP staff before an individual can be authorized for MDCP services.

TMHP staff processes the SK-SAI for an individual 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 an individual or member and establish the individual service plan (ISP) cost limit.

Once TMHP staff process the SK-SAI, the MCO will receive a substantive response file with a three-alphanumeric digit RUG value. This code may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A“BC1” code indicates the SK-SAI does not have all of the information necessary for TMHP staff to accurately calculate a RUG for the individual or member. Code “BC1” is not a valid RUG value 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. If the MCO fails to submit the correction within 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTC Online Portal. Information about the process of transmitting and correcting a SK-SAI is available in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MDCP module of the SK-SAI (Section R, MDCP Related Items) establishes an annual cost limit for each individual or member receiving MDCP services. The cost limit is based on the anticipated cost of the individual/member residing in an NF.

As a part of the ISP planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit. If the MCO does not properly establish this plan of care (POC) and the individual or member’s ISP cost exceeds the individual limit, the MCO must continue to provide MDCP services at the MCO’s expense.

The MCO may not terminate MDCP enrollment if an individual or member’s ISP exceeds the cost limit. The MCO must also adopt a methodology to track each member’s MDCP-related expenditures on a monthly basis and provide an update on MDCP-related expenditures to the member, legally authorized representative (LAR) or authorized representative (AR) no less than once per month.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the MDCP member does not experience gaps in authorizations and authorizations are consistent with information in the member’s ISP.

The member’s MDCP ISP Narrative must include the components of a person-centered ISP, as described in Title 42 Code of Federal Regulations (CFR) §441.301(c)(2) Subpart G, Contents of Request for a Waiver.

2230 Program Support Unit Staff Coordination for an Applicant Enrolling in MDCP

Revision 18-0; Effective September 4, 2018

Within two business days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, Program Support Unit (PSU) staff must ensure the applicant has met all the following eligibility criteria:

  • is under age 21 in the Texas Integrated Eligibility Redesign System (TIERS);
  • is a Texas resident in TIERS;
  • has an approved medical necessity (MN) in the TMHP LTC Online Portal;
  • has an individual service plan (ISP) with at least one Medically Dependent Children Program (MDCP) service; and
  • has an ISP within the individual’s cost limit.

For an applicant needing a Medicaid eligibility financial decision, PSU staff must also notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days that the applicant meets MN and document this notification in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. This notification must be documented on Form H1746-A, MEPD Referral Cover Sheet, and faxed within two business days to the MEPD specialist.

The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool. PSU staff must upload the MEPD specialist’s determination in the HEART case record.

The start of care (SOC) date for MDCP services is the first day of the month following the applicant meeting all the eligibility criteria.

Example: If a managed care organization (MCO) submits all eligibility criteria on March 1 and PSU staff verifies the applicant meets all eligibility criteria on March 3, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month following the applicant meeting all eligibility criteria. The eligibility date on Form H2065-D, Notification of Managed Care Program Services, will be April 1.

Example: If an MCO submits all eligibility criteria on March 31 and PSU staff verifies the applicant meets all eligibility criteria on April 2, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month following the applicant meeting all eligibility criteria. The eligibility date on Form H2065-D will be April 1. The individual met the eligibility criteria on March 31. Delay in services must not occur due to PSU staff processing times.

Eligibility must be approved by PSU staff within two business days of the applicant meeting all eligibility criteria and receiving Form H3676 and Form 2604 from the MCO. PSU staff must generate Form H2065-D in the TMHP LTC Online Portal and:

  • mail the original Form H2065-D to the applicant;
  • email Enrollment Resolution Services (ERS) the following information:
    • the applicant’s name;
    • Medicaid identification (ID) number;
    • type of request (interest list or Money Follows the Person (MFP));
    • date of MFP limited nursing facility (NF) stay, if applicable;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment; and
    • Form H2065-D;
  • document the interest list closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable documents to HEART case record and close the HEART case record using the appropriate closure code.

The MCO must monitor the TMHP LTC Online Portal for the status of the member’s ISP and to retrieve Form H2065-D.

2240 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022

 

2300, Interest List Release Closures

Revision 21-10; Effective October 25, 2021

An individual can be placed on multiple interest lists but may only enroll in one Medicaid waiver program at a time.

The individual may choose to:

  • Pursue eligibility for another program and decline Medically Dependent Children Program (MDCP) at the time of interest list release; or
  • Decline MDCP at the time of interest list release but choose to remain on the MDCP interest list.

Individuals who decline MDCP at the time of interest list release but choose to remain on the MDCP interest list will move to the bottom of the interest list.

Program Support Unit (PSU) staff must complete the following activities within two business days if the individual chooses to decline MDCP and wants to continue receiving or pursue eligibility for another program:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • Close the MDCP interest list release in the Community Services Interest List (CSIL) database using the date the individual declined MDCP;
  • Document the closure date, the individual’s reason for requesting closure and how PSU staff received the individual’s request for closure (e.g., if by telephone, then document the date, caller’s name and caller’s contact information) in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document and close the HEART case record using the appropriate closure reason. 

2310 Contacting the Interest List Management Unit to Reopen a Closed Interest List Release

Revision 20-4; Effective December 18, 2020

Program Support Unit (PSU) staff must submit a request to Interest List Management (ILM) Unit staff to reopen an individual’s closed interest list record.

Within two business days of receiving the request to reopen a closed interest list release, PSU staff must email their immediate supervisor to reopen the Community Services Interest List (CSIL) record. The email must include the following:

  • an email subject line that reads: “MDCP Reopen Request for XX [individual’s first and last initials].” For example, the email subject line for a request to reopen a closed CSIL record for Ann Smith would be “MDCP Reopen Request for AS”;
  • individual’s name;
  • interest list identification (ID) number;
  • individual’s Medicaid ID or Social Security number (SSN);
  • the individual’s, authorized representative’s (AR’s) or legally authorized representative’s (LAR’s) contact name and phone number; and
  • reason for the request to reopen. For example, a statement indicating that the application for an alternate 1915(c) Medicaid waiver program was denied and the individual now wishes to reapply for MDCP.

The PSU supervisor will forward the reopen request to the ILM Unit manager at StarPlusWaiverInterestList@hhsc.state.tx.us if the PSU supervisor agrees the reopen request is appropriate. ILM Unit staff will email PSU staff to provide the outcome of the request within five business days.

If an exception is granted, PSU staff must:

  • contact the individual to begin the application process;
  • document the reopen request in the Health and Human Services Enterprise Administrative Report and Tracking System (HEART) case record;
  • upload the ILM Unit staff’s decision email to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • keep the HEART case record open until MDCP eligibility is approved or denied.

If an exception is not granted, PSU staff must:

  • upload the ILM Unit staff’s decision email to the HEART case record, following the instructions in Appendix XVIII; and
  • close the HEART case record. 

2320 Earliest Date for Adding an Individual Back to the Interest List After Denial or Termination

Revision 18-0; Effective September 4, 2018

The earliest date an individual may be added back to the Community Services Interest List (CSIL) database, for the same program the individual is denied, is the date the individual is determined to be ineligible for the program.

Example: The individual is released from the Medically Dependent Children Program (MDCP) interest list on August 2. The individual is denied eligibility for MDCP on August 28, and a notification is sent to the individual of ineligibility. The first date the denied individual can be added back to the MDCP interest list is August 28.

Example: The individual’s MDCP services are terminated July 31 due to denial of medical necessity (MN). The first date the individual can be added back to the MDCP interest list is August 1. The earliest date an individual may be added back to the CSIL database for the same program the individual is terminated from is the first date the individual is no longer eligible for the terminated program, which in this example is August 1.

2400, Money Follows the Person

2410 Traditional Money Follows the Person

Revision 23-3; Effective May 22, 2023

The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports (LTSS). The managed care organization (MCO) performs the functional assessment and service planning for residents who need the Medically Dependent Children Program (MDCP) services upon discharge from the NF.

Individuals in an NF are assigned permanency planners. The permanency planner coordinates permanency planning through the traditional MFP process into MDCP. The state-contracted permanency planner is EveryChild Inc. 

Permanency planning is:

  • the placement process for a child in an NF; and
  • "A philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Title 4 Texas Government Code Section 531.151). 

An individual receiving NF Medicaid must request MDCP while living in an NF and remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

An individual without Medicaid must:

  • request MDCP while residing in an NF;
  • reside in an NF for no less than 30 days or until Medicaid eligibility is approved; and
  • remain in the NF until PSU staff make a final eligibility determination for MDCP.

PSU staff must refer to Section 2411, Medically Dependent Children Program Eligibility, and 2411.1, Texas Administrative Code Medically Dependent Children Program Eligibility Requirements, for more information about MDCP eligibility requirements.

Individuals who meet the medically fragile criteria and are not able to live in an NF for a minimum of 30 days or until Medicaid is approved may be able to enter MDCP through the MFP Limited NF stay process.

PSU staff must refer to Section 2420, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual, for more information about the MFP limited NF stay process.

2411 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;
  • reside 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 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.

An individual receiving Medicaid NF services is approved for MDCP if: 

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

An individual without Medicaid eligibility must reside in an NF for no less than 30 days or until Medicaid eligibility is approved. 

An individual is denied immediate enrollment if the individual discharges from the NF before being determined eligible for MDCP. 

2411.1 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 in order 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: 
    • the person's home; or 
    • an agency foster home as defined in Texas Human Resource Code, Section 42.002, (relating to Definitions); and 
  • 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 is approved for MDCP if the applicant:

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

2411.2 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). 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.

PSU staff must refer to the following sections for the information about MN determination procedures for MDCP applicants pursing eligibility through the traditional Money Follows the Person (MFP) process: 

  • Section 2412.3, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Managed Care Organization Coordination, for non-STAR Kids nursing facility residents; and
  • Section 2413.3, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Managed Care Coordination, for STAR Kids nursing facility residents. 

2412 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents 

Revision 22-3; Effective Sept. 9, 2022 

The individual’s permanency planner, Every Child, Inc., contacts the Interest List Management (ILM) Unit within two business days from the individual’s Medically Dependent Children Program (MDCP) selection date to:

  • notify the Texas Health and Human Services Commission (HHSC) that the individual has selected MDCP through the traditional Money Follows the Person (MFP) process; and
  • update the individual’s address on file, if needed.

Note: Other entities may contact the ILM Unit to provide notification of an individual’s request to pursue MDCP through the traditional MFP process. These entities may include the:

  • legally authorized representative (LAR);
  • individual; or 
  • nursing facility (NF). 

2412.1 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Interest List Management Responsibilities 

Revision 22-3; Effective Sept. 9, 2022 

Interest List Management (ILM) Unit staff complete the following activities for a non-STAR Kids nursing facility (NF) individual who requests to pursue the Medically Dependent Children Program (MDCP) through the traditional Money Follows the Person (MFP) process:

  • create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database; or
  • add the individual to the interest list if they are not on the interest list;
  • immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • assign the MDCP case record in HEART to Program Support Unit (PSU) staff. 

2412.2 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit Responsibilities

Revision 22-3; Effective Sept. 9, 2022

 

2412.2.1 Enrollment Following Interest List Release Bypass 

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days of the receipt of a traditional Money Follows the Person (MFP) Medically Dependent Children Program (MDCP) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and document the Medicaid type; 
  • determine if Form H1200, Application for Assistance – Your Texas Benefits, is required in the enrollment packet;
    • refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200 to determine Medicaid financial eligibility;
  • contact or attempt to contact the individual or legally authorized representative (LAR) by phone to explain the: 
    • Medicaid application process, if applicable; 
    • importance of selecting a STAR Kids managed care organization (MCO); and
    • the importance of promptly returning the enrollment packet, if applicable;
  • mail the following enrollment packet to the individual or LAR:
  • •upload the applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

PSU staff must contact the individual or LAR within 14 days after mailing the enrollment packet to:

  • verify receipt of the enrollment packet;
  • explain the Medicaid application process, if applicable;
  • give a general description of MDCP services;
  • explain the need to select a STAR Kids MCO within 30 days from the mail date of the above enrollment packet;
  • inform the individual or LAR that a delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP;
  • encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual: 
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, if applicable; and
  • advise the individual, LAR or nursing facility (NF) to immediately submit Form H1200 if: 
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • TIERS does not have a record of submission; and
  • document all contact attempts and any delays in the HEART case record. 

PSU staff must check TIERS to verify Form H1200 has been submitted if the applicant, LAR or NF states Form H1200 has already been submitted during the 14-day follow-up contact.

PSU staff must fax Form 1746-A, MEPD Referral Cover Sheet, and Form H1200 to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist within two business days from locating Form H1200 in TIERS without Form H1746-A, if applicable. PSU staff must notate the following on Form H1746-A:

  • Form H1200 is in TIERS; and
  • the applicant is requesting to pursue the MFP process.

PSU staff must review the enrollment packet upon receipt to ensure all documents are completed. PSU staff must complete the following activities within two business days from the date Form H1200 is received:

  • fax Form H1746-A and Form H1200 to the MEPD specialist;
  • notate the applicant is requesting to pursue the MFP process on From H1746-A;
  • record the date Form H1200 was received from the applicant and the date PSU staff faxed Form H1200 to the MEPD specialist in the HEART case record;
  • maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in TIERS; 
  • check TIERS to determine if Form H1200 is received;
  • maintain a copy of page one of Form H1200 in the applicant’s HEART case record;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document the HEART case record.

PSU staff must ensure Form H1200 is signed prior to faxing Form H1200 to the MEPD specialist, if applicable. The MEPD specialist will return the unsigned Form H1200 to PSU staff requesting the applicant or LAR’s signature before processing the application. 

PSU staff must complete the following activities within two business days from notification by the MEPD specialist that Form H1200 is unsigned:

  • contact the applicant or LAR;
  • advise that the application cannot be processed unless Form H1200 is signed; and
  • document the HEART case record.

PSU staff may complete the following activities within two business days from the date PSU staff received an unsigned Form H1200: 

  • generate Form 2606, Managed Care Enrollment Processing Delay, and Form 2606-S;
  • mail Form 2606 with the original unsigned Form H1200 to the applicant; and
  • document the HEART case record.
  • PSU staff must complete the following activities if Form 2606 was mailed:
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document the HEART case record.

PSU staff must check TIERS to verify if Form H1200 and Form H1746-A is received, as applicable. 

PSU staff must document all contact attempts and any delays in the HEART case record. 

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.  

2412.2.2 Managed Care Organization Selection or Default

Revision 22-3; Effective Sept. 9, 2022 

Non-STAR Kids nursing facility (NF) residents pursing the Medically Dependent Children Program (MDCP) though the traditional Money Follows the Person (MFP) process must select a STAR Kids managed care organization (MCO). Program Support Unit (PSU) staff may accept an individual, applicant or legally authorized representative’s (LAR’s) verbal or written STAR Kids MCO selection. The individual, applicant or LAR may provide their written STAR Kids MCO selection on Form H2053-B, Health Plan Selection.

Individuals and applicants have 30 days from the enrollment packet mail date to select a STAR Kids MCO. PSU staff must default the individual or applicant to a STAR Kids MCO if an MCO selection is not received within 30 days from the enrollment packet mail date. The defaulted MCO must be in the individual or applicant’s service area (SA). 

PSU must document all contact attempts and case actions in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. 

2412.2.3 Receipt of Enrollment Packet 

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days from:

  • receiving the completed enrollment packet from a non-STAR Kids nursing facility (NF) resident pursing the Medically Dependent Children Program (MDCP) though the traditional Money Follows the Person (MFP) process; or 
  • a STAR Kids managed care organization (MCO) selection or default:
    • complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating the individual or applicant requests the traditional Money Follows the Person (MFP) option;
    • upload Form H3676, Section A, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
    • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
    • document the HEART case record.

PSU staff must contact the individual or legally authorized representative (LAR) within two business days from the receipt of an enrollment packet that is incomplete, incorrect, or missing information to:

  • obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • obtain missing or corrected information required to process the case if information is missing or incorrect;
  • encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual: 
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, Application for Assistance – Your Texas Benefits, if applicable; and
  • advise the individual or LAR to immediately submit Form H1200 if: 
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in the Texas Integrated Redesign System (TIERS).

PSU must document all contact attempts in the HEART case record.

PSU staff may complete the following activities within two business days from the 30th day of the enrollment packet mail date if the applicant has not returned Form H1200:

  • generate Form 2606, Managed Care Enrollment Processing Delay, and Form 2606-S;
  • mail Form 2606 with the original unsigned Form H1200 to the applicant; and
  • document the HEART case record.
  • PSU staff must complete the following activities if Form 2606 was mailed:
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document the HEART case record. 

2412.3 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Managed Care Organization Coordination

Revision 22-3; Effective Sept. 9, 2022 

The managed care organization (MCO) initiates contact with the individual, applicant, or legally authorized representative (LAR) to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO must complete the STAR Kids Individual Assessment Instrument (SK-SAI) within 30 days from the date Program Support Unit (PSU) staff uploaded Form H3676, Section A, to TxMedCentral. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification. The MCO must submit the SK-SAI to the Texas Health and Human Services (HHSC) Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 72 hours of the assessment’s completion.

TMHP staff process the SK-SAI to determine medical necessity (MN) and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used to establish the STAR Kids individual service plan (SK-ISP) cost limit.

The MCO must correct the information on the SK-SAI within 14 days of submitting an SK-SAI with an error. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP if the MCO fails to submit the correction within 14 days.

The MCO has an additional 30 days to submit all required documentation to PSU staff. The MCO must complete the following activities within 60 days from the receipt of Form H3676, Section A:

  • complete Form H3676, Section B and upload it to TxMedCentral;
  • complete the SK-SAI in the TMHP LTCOP; 
  • obtain the applicant’s physician's signature on Form 2601;
  • complete the SK-ISP; and
  • submit the SK-ISP electronically through the TMHP LTCOP.

PSU staff must monitor TxMedCentral and the TMHP LTCOP, as applicable, for receipt of the completed:

  • Form H3676, Section B; 
  • SK-ISP; and 
  • SK-SAI.

The MCO must complete and submit the SK-SAI and SK-ISP before the NF discharge.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and Persons with Disabilities (MEPD) specialist to notify the MEPD specialist within two business days of the receipt of:

  • a valid SK-ISP; and
  • the SK-SAI if Medicaid is still pending. 

PSU staff must notate the following on Form H1746-A:

  • The applicant has an approved MN; and
  • The applicant has a valid SK-ISP.

PSU staff must check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid eligibility, if applicable.

PSU staff must email the Program Support Operations Review Team (PSORT) mailbox within two business days from the date the MCO fails to submit the initial assessment information within the 60-day timeframe. The email must include: 

  • an email subject line that reads: “MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for Ann Smith would read “MDCP Initial 60-Day 9B MCO Non-Compliance for AS.”
  • the following items in the body of the email:
    • individual or applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code; 
    • the date information was due from the MCO; 
    • a brief description of the delay and any MCO information received; and
  • attachments of any pertinent documents received from the MCO (e.g., Form H2067-MC, Managed Care Programs Communication).

PSU staff must continue to monitor TxMedCentral and the TMHP LTCOP for receipt of the above information. PSU staff must email any case information received from the MCO to the PSORT mailbox within two business days from its receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late initial assessment information. PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • SSN or Medicaid ID number;
    • DOB;
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.
  • PSU staff must: 
  • collaborate, as needed, with all involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document delays;
  • track all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record. 

2412.4 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit Staff Coordination 

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities in one business day following the receipt of all documentation required for the Medically Dependent Children Program (MDCP) eligibility, as well as the Medicaid financial eligibility determination, as applicable:

  • confirm MDCP eligibility by verifying the applicant: 
    • is under 21 years old in the Texas Integrated Eligibility Redesign System (TIERS);
    • is a Texas resident in TIERS;
    • has the appropriate Medicaid type of assistance (TOA) for MDCP in TIERS;
    • has an approved medical necessity (MN) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
    • has a STAR Kids individual service plan (SK-ISP): 
      • with a least one MDCP service; and 
      • within the applicant's cost limit; 
  • manually generate the initial Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • PSU staff must refer to Form H2065-D instructions for more information on field entries;
  • mail the initial Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • 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; and
  • document the HEART case record.

The managed care organization (MCO) collaborates with the applicant, LAR, and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within two business days from determining the discharge date.

PSU staff must upload Form H2067-MC to TxMedCentral following the instructions in Appendix IX within two business days from notification by another entity of a different nursing facility (NF) discharge date. PSU staff must request the MCO confirm which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to TxMedCentral advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to TxMedCentral within two business days before the applicant’s planned NF discharge date to confirm the applicant’s planned discharge date remains the same. The MCO will provide PSU staff with the new NF discharge date if the planned NF discharge date has changed.

PSU staff must complete the following activities within one business day after the NF discharge notification date:

  • approve the SK-ISP in the TMHP LTCOP;
  • electronically generate the final Form H2065-D following the instructions in Appendix II;
    • PSU staff must refer to Form H2065-D instructions for more information on field entries.
    • The start of care (SOC) date is the first of the month in which the discharge occurred. 
  • mail the final Form H2065-D to the member or LAR;
  • upload the final Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
  • fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
  • email Enrollment Resolution Services (ERS) requesting MDCP enrollment. The email must include the following information: 
    • an email subject line that reads, “MDCP MFP Enrollment Request for XX [first letter of the member's first and last name].” For example, the email subject line for a traditional MDCP Money Follows the Person (MFP) enrollment request for Ann Smith would be “MDCP MFP Enrollment Request for AS;”
    • the member's name;
    • Medicaid identification (ID) number;
    • the type of request (i.e., MFP NF discharge);
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • effective date of enrollment; 
    • MN approval date;
    • MCO selection; and
    • Form H2065-D; 
  • close the Community Services Interest List (CSIL)
  • database record using the appropriate closure code; 
  • upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

2412.5 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials 

Revision 23-3; Effective May 22, 2023

An individual without Medicaid must:

  • request the Medically Dependent Children Program (MDCP) while living in a nursing facility (NF);
  • live in an NF for no less than 30 days or until Medicaid eligibility is approved; and
  • remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

The managed care organization (MCO) must upload Form H3676, Care Pre- Enrollment Assessment Authorization, Section B, to TxMedCentral, within two business days from determining the applicant has failed to meet any MDCP eligibility criteria.

PSU staff must deny the MDCP Money Follows the Person (MFP) applicant by manually generating Form H2065-D, Notification of Managed Care Program Services, within two business days from MCO notification if the MDCP MFP applicant has not: 

  • met MDCP eligibility; or 
  • completed the MFP process.

PSU staff must follow the instructions in Appendix II, Form H2065-D MD CP Reason for Denial and Comments Language, when manually generating Form H2065-D.

PSU staff must refer the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the denial of MDCP for STAR Health applicants.

PSU staff must refer to Section 6000, Denials and Terminations, for more information about processing MDCP applicant denials.

PSU staff must notify the Interest List Management (ILM) Unit staff by email at MDCP_Interest_List@hhsc.state.tx.us for all MDCP MFP individuals or applicants who do not meet the MDCP MFP eligibility requirements. The email must include the following information:

  • an email subject line that reads: "MDCP MFP Denial for XX [first letter of the individual’s or applicant’s first and last name]." For example, the email subject line for an MFP denial for Ann Smith would be "MDCP MFP Denial for AS;"
  • the individual or applicant’s name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • contact name and phone number; 
  • the reason for the denial; and
  • the request to return the individual or applicant to the MDCP interest using their original MDCP request date.

PSU staff must not close the Community Services Interest List (CSIL) record for an MDCP MFP applicant.

PSU staff must not:

  • deny MDCP for an MDCP MFP individual; 
  • close the CSIL record for an MDCP MFP individual; or
  • generate and mail Form 2442, Notification of Interest List Release Closure for an MDCP MFP individual.

PSU staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for more information about scenarios where an individual, applicant or member transitions out of MDCP for not meeting the MDCP age requirement.

2413 Traditional Money Follows the Person STAR Kids Nursing Facility Residents

Revision 22-3; Effective Sept. 9, 2022

An individual’s permanency planner, Every Child, Inc., contacts the Interest List Management (ILM) Unit within two business days from the individual’s Medically Dependent Children Program (MDCP) selection date to:

  • notify the Texas Health and Human Services Commission (HHSC) that the individual has selected MDCP under the traditional Money Follows the Person (MFP) process; and
  • update the individual’s address on file, if needed.

Note: Other entities may contact the ILM Unit to provide notification of an individual’s request to pursue MDCP through the traditional MFP process. These entities may include:

  • legally authorized representative (LAR);
  • individual; or 
  • nursing facility (NF). 

2413.1 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Interest List Management Responsibilities

Revision 22-3; Effective Sept. 9, 2022 

Interest List Management (ILM) Unit staff complete the following activities for a STAR Kids nursing facility (NF) individual who requests to pursue the Medically Dependent Children Program (MDCP) through the traditional Money Follows the Person (MFP) process:

  • create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database; or
  • add the individual to the interest list if they are not on the interest list;
  • immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • assign the MDCP case record in HEART to Program Support Unit (PSU) staff. 

2413.2 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Responsibilities

Revision 22-3; Effective Sept. 9, 2022

 

2413.2.1 Enrollment Following Interest List Release Bypass

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days of the receipt of a traditional Money Follows the Person (MFP) Medically Dependent Children Program (MDCP) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and document the Medicaid type; 
  • mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating:
    • the individual or applicant is enrolled in STAR Kids; and
    • requests the traditional Money Follows the Person (MFP) option; 
  • upload Form H3676, Section A, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

PSU staff must contact the individual or LAR within 14 days after mailing the enrollment packet to: 

  • verify receipt of the enrollment packet; and
  • provide a general description of MDCP services.

2413.3 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Managed Care Coordination

Revision 22-3; Effective Sept. 9, 2022 

The managed care organization (MCO) initiates contact with the individual, applicant, or legally authorized representative (LAR) to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO must complete the STAR Kids Individual Assessment Instrument (SK-SAI) within 30 days from the date Program Support Unit (PSU) staff uploaded Form H3676, Section A, to TxMedCentral. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification. The MCO must submit the SK-SAI to the Texas Health and Human Services Commission (HHSC) Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 72 hours of the assessment’s completion.

TMHP staff process the SK-SAI to determine medical necessity (MN) and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used to establish the STAR Kids individual service plan (SK-ISP) cost limit.

The MCO must correct the information on the SK-SAI within 14 days of submitting an SK-SAI with an error. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP if the MCO fails to submit the correction within 14 days.

The MCO has an additional 30 days to submit all required documentation to PSU staff. The MCO must complete the following activities within 60 days from the receipt of Form H3676, Section A:

  • Form H3676, Section B and upload it to TxMedCentral;
  • the SK-SAI in the TMHP LTCOP; 
  • the SK-ISP; 
  • obtain the applicant’s physician's signature on Form 2601; and
  • submit the SK-ISP electronically through the TMHP LTCOP.

PSU staff must monitor TxMedCentral and the TMHP LTCOP, as applicable, for receipt of the completed:

  • Form H3676, Section B; 
  • SK-ISP; and 
  • SK-SAI.

The MCO must complete and submit the SK-SAI and SK-ISP before the NF discharge.

PSU staff must email the Program Support Operations Review Team (PSORT) mailbox within two business days from the date the MCO fails to submit the initial assessment information within the 60-day timeframe. The email must include: 

  • an email subject line that reads: “MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for Ann Smith would read “MDCP Initial 60-Day 9B MCO Non-Compliance for AS.”
  • the following items in the body of the email:
    • individual’s or applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code; 
    • the date information was due from the MCO; 
    • a brief description of the delay and any MCO information received; and
    • attachments of any pertinent documents received from the MCO (e.g., Form H2067-MC, Managed Care Programs Communication)

PSU staff must continue to monitor TxMedCentral and the TMHP LTCOP for receipt of the above information. PSU staff must email any case information received to the PSORT mailbox within two business days of receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late initial assessment information.

PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • SSN or Medicaid ID number;
    • DOB;
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must: 

  • collaborate, as needed, with all involved parties throughout the Medically Dependent Children Program (MDCP) eligibility determination process to assist with problem resolution and to document delays;
  • track all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record. 

2413.4 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Staff Coordination

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities within one business day following the receipt of all documentation required for Medically Dependent Children Program (MDCP) eligibility:

  • confirm MDCP eligibility by verifying the applicant: 
    • is under 21 years old in the Texas Integrated Eligibility Redesign System (TIERS);
    • is a Texas resident in TIERS;
    • has the appropriate Medicaid type of assistance (TOA) for MDCP in TIERS;
    • has an approved medical necessity (MN) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
    • has a STAR Kids individual service plan (SK-ISP): 
      • with a least one MDCP service; and
      • within the applicant’s cost limit;
    • manually generate the initial Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
      • PSU staff must refer to Form H2065-D instructions for more information on field entries;
    • mail the initial Form H2065-D to the applicant or legally authorized representative (LAR);
    • upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
    • upload all applicable documents to the (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
    • document the HEART case record.

The managed care organization (MCO) collaborates with the applicant, LAR, and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within two business days from determining the discharge date.

PSU staff must upload Form H2067-MC to TxMedCentral, following the instructions in Appendix IX, within two business days from notification by another entity of a different nursing facility (NF) discharge date. PSU staff must request the MCO confirm which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to TxMedCentral advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to TxMedCentral within two business days before the applicant’s planned NF discharge date to confirm the applicant’s planned discharge date remains the same. The MCO must provide PSU staff with the new NF discharge date if the planned NF discharge date has changed.

PSU staff must complete the following activities within one business day following the NF discharge notification date: 

  • approve the SK-ISP in the TMHP LTCOP;
  • electronically generate the final Form H2065-D; following the instructions in Appendix II;
    • PSU staff must refer to Form H2065-D instructions for more information on field entries.
    • The start of care (SOC) date is the first of the month in which the discharge occurred. 
  • mail the final Form H2065-D to the member or LAR;
  • upload the final Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
  • email Enrollment Resolution Services (ERS), requesting MDCP enrollment. The email must include the following information: 
    • an email subject line that reads, “MDCP MFP Enrollment Request for XX [first letter of the member's first and last name].” For example, the email subject line for a traditional MDCP Money Follows the Person (MFP) enrollment request for Ann Smith would be “MDCP MFP Enrollment Request for AS;” 
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., MFP NF discharge);
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • effective date of enrollment;
    • MN approval date;
    • MCO; and
    • Form H2065-D; 
  • close the Community Services Interest List (CSIL) database record using the appropriate closure code;
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

2413.5 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials

Revision 23-3; Effective May 22, 2023

An individual receiving nursing facility (NF) Medicaid must request the Medically Dependent Children Program (MDCP) while residing in an NF and remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

The managed care organization (MCO) must upload Form H3676, Care Pre- Enrollment Assessment Authorization, Section B, to TxMedCentral, within two business days from determining the applicant has failed to meet any MDCP eligibility criteria.

PSU staff must deny the MDCP Money Follows the Person (MFP) applicant by manually generating Form H2065-D, Notification of Managed Care Program Services, within two business days from MCO notification if the MDCP MFP applicant has not: 

  • met MDCP eligibility; or 
  • completed the MFP process.

PSU staff must follow the instructions in Appendix II, Form H2065-D MD CP Reason for Denial and Comments Language, when manually generating Form H2065-D.

PSU staff must refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the denial of MDCP for STAR Health applicants.

PSU staff must refer to Section 6000, Denials and Terminations, for more information about processing MDCP applicant denials.

PSU staff must notify the Interest List Management (ILM) Unit staff by email at MDCP_Interest_List@hhsc.state.tx.us for all MDCP MFP individuals or applicants who do not meet the MDCP MFP eligibility requirements. The email must include the following information:

  • an email subject line reads: “MDCP MFP Denial for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for an MFP denial for Ann Smith would be “MDCP MFP Denial for AS;”
  • the individual or applicant's name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • contact name and phone number; 
  • the reason for the denial; and
  • the request to return the individual or applicant to the MDCP interest list using their original MDCP request date.

PSU staff must not close the Community Services Interest List (CSIL) record for an MDCP MFP applicant.

PSU staff must not:

  • deny MDCP for an MDCP MFP individual; 
  • close the CSIL record for an MDCP MFP individual; or
  • generate and mail Form 2442, Notification of Interest List Release Closure, for an MDCP MFP individual.

PSU staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for more information about scenarios where an individual, applicant or member transitions out of MDCP for not meeting the MDCP age requirement.

2414 MDCP Money Follows the Person Delays in NF Discharge

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff and the managed care organization (MCO) must use their judgment and work with a Medically Dependent Children Program (MDCP) traditional Money Follows the Person (MFP) applicant who has community living arrangements pending but not finalized. 

PSU staff must keep the request for services open if the applicant has an estimated discharge date beyond a four-calendar month period.

PSU staff must refer traditional MFP cases pending beyond four calendar months to the PSU supervisor when an applicant: 

  • has not established living arrangements to return to the community;
  • cannot decide when to return to the community; or 
  • has no viable plan or support system in the community.

2415 Money Follows the Person Demonstration (MFPD) References in STAR Kids

Revision 22-3; Effective Sept. 9, 2022 

Money Follows the Person Demonstration (MFPD) does not apply to the Medically Dependent Children Program (MDCP). Children transition to the least restrictive setting under the traditional Money Follows the Person (MFP) program. For this reason, managed care organizations (MCOs) are not required to track an individual or applicant’s enrollment period or seek informed consent from an individual, applicant, or legally authorized representative (LAR). Program Support Unit (PSU) staff must disregard the "MFPD" check box on Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. 

2420 Money Follows the Person Limited NF Stay Option for a Medically Fragile Individual

Revision 18-0; Effective September 4, 2018

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but is too medically fragile to reside in an NF for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

  • ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap));
  • renal dialysis;
  • 24 hour/day supplemental oxygen dependence;
  • total nutrition through enteral tube feeding;
  • total parenteral nutrition (TPN);
  • seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
  • documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
  • congestive heart failure requiring hospitalization and routine medication within the past six months; or
  • in hospice care.

An individual determined to be medically fragile and is approved for a limited NF stay, must stay at least part of two consecutive days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress to the individual, legally authorized representative (LAR) or authorized representative (AR), in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from an NF on a Friday, Saturday, Sunday, or any day preceding a state holiday as services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy. 

2421 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 18-0; Effective September 4, 2018

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual’s name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in bypassing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to bypass the MDCP interest list:

  • STAR Kids program, if not enrolled;
  • an overview of MDCP services;
  • the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
  • the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
  • Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
  • required medical documentation from the individual’s clinical record at the physician’s office, hospital or clinic (not from a patient portal) must be within 12 months of the date the documentation is submitted to ILM Unit staff; and
  • admission and discharge documentation from the NF will be required.

ILM Unit staff will mail Form 2406 to the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian, LAR or AR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian, LAR or AR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered. 

2422 Money Follows the Person Limited Nursing Facility Stay Procedures

Revision 18-0; Effective September 4, 2018 

 

2422.1 Processing Form 2406 and Medical Documents

Revision 18-0; Effective September 4, 2018

Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed by the individual’s physician, licensed to practice in the state of Texas through the Texas Medical Board, and signed by the physician within 90 days of receipt by Interest List Management (ILM) Unit staff, to be considered for the Money Follows the Person (MFP) limited nursing facility (NF) stay option. The Texas physician must attach to Form 2406 documentation (such as a visit note or hospital discharge summary) of chronic conditions. The medical documentation provided must include:

  • documentation of the individual’s chronic conditions and the current health status of the individual  that will substantiate the boxes checked on Form 2406; and
  • medical records from within 12 months of the date the documentation is being submitted. Medical records must be physician-originated (not from a patient portal).

Upon receipt of Form 2406 and medical documentation, ILM Unit staff will identify the physician’s recommendation.

If the individual’s physician attests the individual does meet the medically fragile criteria and is too medically fragile to reside in an NF setting for an extended period of time on Form 2406, ILM Unit staff will verify the following within two business days:

  • the individual’s name and date of birth are present and legible on Form 2406;
  • the individual is under age 21;
  • the physician’s name, address, license number, signature and date are on Form 2406;
  • physician that signed Form 2406 is licensed in the state of Texas by conducting a license search on the Texas Medical Board’s website; and
  • physician signature on Form 2406 is within 90 days of receipt.

If Form 2406 contains all required information and medical documentation appears to be from an appropriate source and dated within the allowable date range, ILM Unit staff will email all documents to the Texas Health and Human Services Commission (HHSC) nurse to determine if the individual meets the medically fragile criteria. ILM Unit staff must submit each request in a separate email to the HHSC nurse. The email’s subject line must read: Medically Dependent Children Program Form 2406 for XX. The “XX” in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "Medically Dependent Children Program Form 2406 for AS."

ILM Unit staff must place the individual in a “Release” status in the Community Services Interest List (CSIL) database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will also create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and upload Form 2406. ILM Unit staff must not upload medical records to the HEART case record.

If the individual’s physician attests the individual does not meet the medically fragile criteria for a limited NF stay, ILM Unit staff must contact the individual within two business days, to inform him or her of the physician’s recommendation. The individual can remain on the interest list until his or her name reaches the top, or follow the traditional MFP option as described in Section 2410, Traditional Money Follows the Person.

If Form 2406 does not contain the required information, ILM Unit staff must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within two business days of receipt to discuss the elements of the form that are incomplete, and that Form 2406 and associated documents will be returned.

This includes medical documentation that is over 12 months old or not from an appropriate source (such as a patient portal). The individual, parent, guardian, LAR or AR, may submit additional records to satisfy the medical record requirement. If additional records are not submitted before the physician signature on Form 2406 expires (90 days from the physician signature date), the Medically Dependent Children Program (MDCP) MFP limited NF stay interest list request will remain in an “Open” status until the individual reaches the top of the interest list and no additional action is taken. 

2423 HHSC Nurse or Physician Review of Medical Fragility

Revision 18-0; Effective September 4, 2018

A Texas Health and Human Services Commission (HHSC) nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and medical documentation within two business days to determine if an individual meets the limited nursing facility (NF) stay criteria.

If the individual’s physician attests the individual meets the medically fragile criteria and the physician’s documentation clearly substantiates the individual meets two or more criteria on Form 2406, the HHSC nurse may approve the limited NF stay request. Within two business days of the decision, the HHSC nurse will document his or her decision that the individual “meets criteria” in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

If the documentation does not substantiate the individual meets two or more criteria on Form 2406, the HHSC nurse will forward Form 2406 and associated medical records to the HHSC physician for a decision. ILM Unit staff are also included in the email. 

2424 Physician Determination of Medical Fragility

Revision 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the ILM Unit staff and reply all to notify ILM Unit staff of the decision. 

2425 Individual Not Meeting the Medically Fragile Criteria

Revision 18-0; Effective September 4, 2018

If the Texas Health and Human Services Commission (HHSC) physician determines the individual does not meet the medically fragile criteria, Interest List Management (ILM) Unit staff will contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) by telephone within two business days of receipt of the HHSC physician’s decision email. If the HHSC physician has a comment regarding the information submitted, this will be noted in the HHSC physician response to ILM Unit staff. ILM Unit staff must include this comment when advising the individual of the outcome of the limited nursing facility (NF) stay request. ILM Unit staff will inform the individual that a limited NF stay is not approved and the individual has the option to transition from an NF stay, as described in Section 2410, Traditional Money Follows the Person, to access Medically Dependent Children Program (MDCP) through the Money Follows the Person (MFP) traditional option.

If the individual does not choose to complete an NF stay as described in Section 2410, his or her name will return to an “Open” status in the Community Services Interest List (CSIL) database and the “Residing in a Nursing Facility” bypass code removed. The individual will remain on the interest list until his or her name comes to the top of the list. If the individual, parent, guardian, LAR or AR requests to reapply for the limited NF stay process, ILM Unit staff must inform the individual, parent, guardian, LAR or AR that a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered. 

2426 ILM Unit Procedures for Assigning an Individual Approved for a Limited NF Stay to PSU Staff

Revision 18-0; Effective September 4, 2018

Within two business days of an individual being approved for a limited nursing facility (NF) stay, Interest List Management (ILM) Unit staff must assign the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to the appropriate Program Support Unit (PSU) staff. No further action is required for ILM Unit staff. 

2427 PSU Procedures for an Individual Approved for a Limited NF Stay

Revision 18-0; Effective September 4, 2018

Within two business days of Program Support Unit (PSU) staff receiving the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment from Interest List Management (ILM) Unit staff, PSU staff must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual receives Medicaid. 

2427.1 PSU Procedures for an Individual Approved for a Limited NF Stay without Medicaid (Including an Individual Enrolled in CHIP)

Revision 21-10; Effective October 25, 2021

An individual who does not receive Medicaid and is not enrolled in a managed care organization (MCO) requesting a Money Follows the Person (MFP) limited stay must go through the process of MCO selection, medical necessity (MN) assessment and financial eligibility determination, including individuals enrolled in the Children’s Health Insurance Program (CHIP).

Interest List Management (ILM) Unit staff complete the following activities for individuals who are on the Medically Dependent Children Program (MDCP) interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within five days of the MDCP case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Contact the individual or LAR to:
    • Verify receipt of the enrollment packet;
    • Confirm interest in MDCP;
    • Explain the Medicaid application process;
    • Give a general description of MDCP services;
    • Explain the need to select an MCO as quickly as possible;
    • Inform the individual or LAR that any delay in selecting an MCO could result in a delay in an eligibility determination for MDCP;
    • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
    • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible; and
  • Advise the individual or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS;
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200;
  • Ensure the individual or LAR understands the MFP limited stay process by advising the individual that the MFP limited stay:
    • Must be coordinated with the MCO service coordinator;
    • Cannot be completed until notified by the MCO service coordinator;
    • Requires the individual, applicant or LAR to present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the MFP limited stay admission and discharge;
    • Must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
    • Process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual does not have an interest in pursuing MDCP services.

PSU staff must complete the following activities within two business days of the receipt of a completed Form H1200:

  • Check TIERS to verify Medicaid eligibility;
  • Fax the signed and completed Form H1200 and all financial verifications to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, along with Form H1746-A identifying the application is for an MDCP MFP limited stay applicant and eligibility must be expedited and assigned immediately; and
  • Email OESMEPDIC@hhsc.state.tx.us that documents have been faxed to MEPD and advise them to expedite the applicant's eligibility process. The email’s subject line must read: “MDCP Request for Expedited Processing for XXX.XXX.” The “XXX.XXX” in the title represents the first three letters of the applicant’s first and last name. For example, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for ANN.SMI." These assignments will be special assigned by an MEPD complaint resolution specialist. PSU staff must also cc OESCCCIC@hhsc.state.tx.us. The purpose of this email is to advise MEPD:
    • PSU staff have faxed Form H1200 to the MEPD specialist; and
    • to expedite the applicant’s eligibility process since this case is an MFP limited stay case; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual or LAR:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant or LAR:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select an MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited stay without an SK-SAI with an approved MN determination.

PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection and interest in MDCP. PSU staff must assign an MCO based on criteria developed by HHSC from the list of available MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes an MCO selection or from the date they are defaulted to an MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual, applicant or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual, applicant or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual, applicant or LAR:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200; and
  • Advise the individual, applicant or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS.

PSU staff must refer to Section 2428, PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay, for PSU and MCO coordination for MFP limited stay applicants. 

2427.2 PSU Procedures for an Individual Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids

Revision 21-10; Effective October 25, 2021

An individual with Medicaid who is not enrolled in a STAR Kids managed care organization (MCO) requesting a Money Follows the Person (MFP) limited stay must go through the process of STAR Kids MCO selection, medical necessity (MN) assessment and financial eligibility determination, if applicable.

Interest List Management (ILM) Unit staff complete the following activities for individuals who are on the Medically Dependent Children Program (MDCP) interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within five days of the MDCP case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Contact the individual or LAR to:
    • Verify receipt of the enrollment packet;
    • Confirm interest in MDCP;
    • Explain the Medicaid application process, if applicable;
    • Give a general description of MDCP services;
    • Explain the need to select a STAR Kids MCO as quickly as possible;
    • Inform the individual or LAR that any delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP services;
    • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
      • has not selected a STAR Kids MCO;
      • has not expressed interest in MDCP; or
      • has not provided Form H1200, if applicable; and
    • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
    • Advise the individual or LAR to immediately submit Form H1200 if:
      • the individual requires Form H1200 to determine Medicaid financial eligibility; and
      • PSU staff do not see Form H1200 in TIERS;
    • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200, if applicable; and
    • Ensure the individual or LAR understands the MFP limited stay process by advising the individual that the MFP limited stay:
      • must be coordinated with the MCO service coordinator;
      • cannot be completed until notified by the MCO service coordinator;
      • requires the individual, applicant or LAR to present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the MFP limited stay admission and discharge;
      • must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
      • process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual does not have an interest in pursuing MDCP services.

PSU staff must complete the following activities within two business days of the receipt of a completed Form H1200, if appropriate:

  • Check TIERS to verify Medicaid eligibility;
  • Fax the signed and completed Form H1200, if available, and all financial verifications to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, along with Form H1746-A, identifying the application is for an MDCP MFP limited stay applicant and eligibility must be expedited and assigned immediately; and
  • Email OESMEPDIC@hhsc.state.tx.us that documents have been faxed to MEPD and advise them to expedite the applicant's eligibility process. The email’s subject line must read: “MDCP Request for Expedited Processing for XXX.XXX.” The “XXX.XXX” in the title represents the first three letters of the applicant’s first and last name. For example, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for ANN.SMI." These assignments will be special assigned by an MEPD complaint resolution specialist. PSU staff must also cc OESCCCIC@hhsc.state.tx.us. The purpose of this email is to advise MEPD:
    • PSU staff have faxed Form H1200 to the MEPD specialist; and
    • to expedite the applicant’s eligibility process since this case is an MFP limited stay case; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual or LAR:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant, if applicable:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select a STAR Kids MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited stay without an SK-SAI with an approved MN determination.

PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection or interest in MDCP. PSU staff must assign a STAR Kids MCO based on criteria developed by HHSC from the list of available STAR Kids MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected a STAR Kids MCO within 30 days from the enrollment packet mail date.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes a STAR Kids MCO selection or from the date they are defaulted to a STAR Kids MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual, applicant or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual, applicant or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual, applicant or LAR:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual, applicant or LAR to immediately submit Form H1200, if:
    • the individual or applicant requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

PSU staff must refer to Section 2428, PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay, for PSU and MCO coordination for MFP limited stay applicants. 

2427.3 PSU Procedures for an Individual Approved for a Limited NF Stay and Currently Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

When an individual who is enrolled in STAR Kids is approved for a limited nursing facility (NF) stay as outlined in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within two business days of Program Support Unit (PSU) staff assignment, PSU staff must complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating the applicant is a Supplemental Security Income (SSI) Money Follows the Person (MFP) individual. PSU staff also complete Section A of Form H3676 stating the member resides at home. In the comments section, indicate this is a STAR Kids member approved for the Medically Dependent Children Program (MDCP) MFP limited NF stay option and post Form H3676 to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, PSU staff must contact the applicant, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) to ensure the applicant understands the limited NF stay must be coordinated with his or her managed care organization (MCO) service coordinator and cannot be completed until he or she is notified by the service coordinator. 

2428 PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 18-0; Effective September 4, 2018

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral advising the MCO of the decision to complete a limited NF stay. The STAR Kids Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, parent, guardian, LAR or AR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the limited NF stay, and the individual must present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the limited NF stay admission and discharge. Form 3618 must be received by the MCO and posted to TxMedCentral by the MCO the same date as the NF discharge or MDCP services cannot be authorized. The MCO must explain the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must explain the individual must not proceed with the limited NF stay until he or she is authorized to do so by the MCO. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) limited NF stay funding requirements. MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. MCO service coordinators must ensure Form 3618 is posted to TxMedCentral for Program Support Unit (PSU) staff to access the same day of NF discharge. Form 3618 is the only instrument accepted to verify the appropriate NF admission and discharge requirement. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy and MDCP services will not be authorized.

The MCO has 60 days to complete all assessments and submit required forms to PSU staff. The MCO must complete:

  • Section B of Form H3676, noting "MFP Limited NF Stay Assessment Completed" in the comments section;
  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items;
  • the electronic Form 2604, Individual Service Plan - Service Tracking Tool; and
  • Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.

The MCO must post Form H3676 to TxMedCentral in the MCO STAR Kids folder and submit the electronic Form 2604 in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. If the applicant is medical assistance only (MAO) and does not have a Medicaid identification (ID) number at the time the MCO is attempting to upload Form 2604 into the TMHP LTC Online Portal, the MCO uses “+” in the designated field for Medicaid ID. Once the applicant has been authorized for MDCP services for 30 days, a Medicaid ID number will be assigned to the individual and the Texas Integrated Eligibility Redesign System (TIERS) will update the TMHP LTC Online Portal. Refer to Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for additional information. The MCO must maintain a copy of Form 2603 in the applicant’s or member’s MCO case file.

If the MCO does not submit an ISP in the TMHP LTC Online Portal within 60 days after PSU staff posted Form H3676, Section A, PSU staff notify Managed Care Compliance & Operations by email indicating the MCO delinquency in performing the assessment.

Within two business days of receiving Form H3676 in TxMedCentral and Form 2604 in the TMHP LTC Online Portal, PSU staff verify the member:

  • is under age 21 in TIERS;
  • is a Texas resident in TIERS;
  • has an approved MN in the TMHP LTC Online Portal;
  • has ongoing financial eligibility in TIERS or by an email through the Medicaid for the Elderly and People with Disabilities (MEPD) Communication Tool stating Medicaid is approved pending the limited NF stay and 30 days of MDCP authorization;
  • has an ISP within the individual’s cost limit; and
  • has authorization of at least one MDCP service on the ISP.

For STAR Kids members accessing MDCP through the limited NF stay process, if the above criteria are met except for the limited NF stay, PSU staff post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions,  to notify the MCO of the MDCP approval pending completion of the limited NF stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited NF stay and MDCP authorization, PSU staff can approve the individual to move forward to complete the limited NF stay as long as all other eligibility criteria are met and MEPD has communicated to PSU staff that the individual is eligible for Medicaid except for the NF stay and 30 days of MDCP authorization. PSU staff post Form H2067-MC to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, to notify the MCO to proceed with the limited NF stay. The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by posting Form H2067-MC to TxMedCentral, following the instructions in Appendix IX.

The MCO service coordinator must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR, AR, NF staff and PSU staff. Form 3618 must be completed by the NF and submitted to the MCO service coordinator within 24 hours of the time of discharge. The NF must understand the importance of processing and providing Form 3618 to the family and/or MCO service coordinator prior to NF discharge.

MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy and MDCP services will not be authorized.

Within 24 hours of the limited NF stay, the following activities must occur:

  • the MCO must notify PSU staff the limited NF stay occurred by posting Form H2067-MC in TxMedCentral, following the instructions in Appendix IX, requesting PSU staff approve MDCP services;
  • the MCO must post Form 3618 to TxMedCentral in the MCO’s STAR Kids folder;
  • PSU staff must respond to the MCO on Form H2065-D, Notification of Managed Care Program Services, by posting to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, noting the applicant or member is pending approval of Medicaid eligibility; however, the applicant or member is eligible for MDCP services and the MCO must send an authorization to the selected provider to begin services; and
  • PSU staff upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

Once the MCO notifies PSU staff that the applicant is authorized to receive MDCP services, within two business days, PSU staff must:

  • complete and mail the original Form H2065-D to the member, LAR or AR;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record;
  • fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist, indicating the individual has transferred from an NF to the MDCP, if applicable;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, if Form H2065-D was manually completed;
  • email Enrollment Resolution Services (ERS), if applicable, with the following:
    • the individual’s name;
    • Medicaid identification (ID) number;
    • type of request (MFP limited stay);
    • date of MFP limited NF stay;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment;
    • Form H2065-D; and
  • upload all applicable documents in HEART case record.

The MDCP effective date will be the first of the month in which the MFP individual was discharged from the NF.

Example: An individual who is not enrolled in STAR Kids leaves the NF December 12, 2016, and begins MDCP services December 12, 2016. The eligibility date on Form H2065-D will be December 1, 2016.

After the individual has been determined eligible for MDCP, ERS updates the individual’s Texas Integrated Eligibility and Redesign System (TIERS) record to indicate managed care enrollment, if applicable.

MCOs must monitor the TMHP LTC Online Portal for the status of their member’s ISP and to retrieve Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must post within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff must:

  • manually complete Form H2065-D;
  • mail the final Form H2065-D to the individual;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • fax Form H2065-D and Form H1746-A to the MEPD specialist, if applicable;
  • email Enrollment Resolution Services (ERS), if applicable;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable documents to the HEART case record.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D. 

2429 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request the MEPD specialist to delay Medicaid certification. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and fax Form H1746-A to the MEPD specialist. Form H1746-A must be uploaded to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending.” If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application. Once PSU staff confirm the Medicaid denial, PSU staff must deny Medically Dependent Children Program (MDCP) eligibility by:

  • manually completing Form H2065-D, Notification of Managed Care Program Services;
  • mail the original Form H2065-D to the applicant or member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • fax Form H2065-D and Form H1746-A to the MEPD specialist;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload Form H2065-D and all other applicable documents to the HEART case record and close the HEART case record.

MCOs must monitor the TMHP LTC Online Portal for the status of their member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting ILM Unit staff, as described in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian, LAR or AR requesting to reopen the Medicaid application. The MCO must post the letter on TxMedCentral in the MCO STAR Kids folder. PSU staff must fax the letter with Form H1746-A marked “Application” to the MEPD specialist within two business days. The MEPD specialist’s time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to the MEPD specialist, PSU staff must request the MEPD specialist delay certification. However, the MEPD specialist may not approve additional requests for delay in certification based on the amount of time that has passed since the original application file date.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by posting Form H2067-MC in TxMedCentral, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian, LAR or AR that a new Form H1200 must be completed.

3100, STAR Kids Screening and Assessment

Revision 18-0; Effective September 4, 2018

All children and young adults enrolled with a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

Once an MCO has completed the SK-SAI and Community First Choice (CFC), Personal Care Services (PCS) and/or Medically Dependent Children Program (MDCP) services have been determined, it is the responsibility of the MCO to communicate to the existing provider the approved service amount, duration and scope. If a new service is approved the member, legally authorized representative (LAR) or authorized representative (AR) should notify the MCO of the intended provider of services and the MCO will reach out to the provider.

3200, Member Reassessment

Revision 18-0; Effective September 4, 2018

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days prior to the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid eligibility. Before the end date of the annual SK-SAI, the MCO must initiate a reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the end of the ISP. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about the Consumer Directed Services (CDS) option and Service Responsibility Option (SRO). The MCO is expected to complete the same activities for each annual assessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member, legally authorized representative (LAR) or authorized representative (AR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive Personal Care Services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized PCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The MCO must also complete the NCAM at any time the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

3210 Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022 

A member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

  • be birth through 20;
  • reside 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 services and supports;
  • not 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.

3210.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 22-3; Effective Sept. 9, 2022 

A member must meet the following criteria as stated in Title 1 Texas Administrative Code (TAC) Section 353.1155 in order 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).

3210.2 Reassessment of Medical Necessity Determination

Revision 23-4; Effective Aug. 21, 2023

A Medically Dependent Children Program (MDCP) member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before Program Support Unit (PSU) staff recertifies the member for MDCP. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI).

The managed care organization (MCO) is not required to get a physician’s signature on Form 2601, Physician’s Certification, for reassessments.

The MCO completes and submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care Online Portal (LTCOP) annually. The TMHP nurse or physician processes the SK-SAI and redetermines the member’s Resource Utilization Group (RUG) value and MN.

PSU staff must monitor the TMHP LTCOP every five business days until the MN status updates to one of the final statuses below:

  • MN Approved: The status may change to "MN Approved" if the TMHP physician overturns the denial because more information is received; or 
  • Overturn Doctor Review Expired: The status may change to "Overturn Doctor Review Expired" when the 14-business day period for the TMHP physician to overturn the denied MN has expired, and no additional or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the member, legally authorized representative (LAR), or medical consenter requests a state fair hearing.

Refer to Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, for more information about state fair hearings regarding MN denials.

The MCO must notify PSU staff of a member’s MN denial and request Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral. Refer to Section 6000, Denials and Terminations, for more information about processing MN terminations. Refer to Section 3328, Reassessment Notification Requirements, for more information about PSU notification requirements.

Refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the termination of MDCP for STAR Health members.

The MCO uses the SK-SAI to create the member’s reassessment STAR Kids individual service plan (SK-ISP). The SK-ISP lists the member’s services and preferences for care. 

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 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.

The MCO must:

  • Track the SK-SAI and SK-ISP renewal dates to ensure all member reassessment activities are completed within 30 days before the SK-ISP expiration date. 
  • Not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the previous SK-SAI. 
  • Submit the SK-SAI in the TMHP LTCOP no earlier than 90 days before or no later than 30 days before the expiration of the member’s current SK-ISP on file. 
  • Upload Form H2067-MC to TxMedCentral documenting any reason for a delay.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox monthly. The ISP Expiring Report details members with SK-ISPs that expire within the next 90 days. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs reported as an MCO non-compliance. The subject line for the email must read: “MDCP Reassessment Delinquencies for [Month]”.

PSU staff are not required to send a follow-up email to PSORT when the MCO submits the following documents for reassessment delinquencies: 

  • Form H2067-MC; 
  • the SK-SAI; or 
  • the SK-ISP.

Refer to Section 3327.1, Process for Reviewing the Individual Service Plan Expiring Report, for more information about the ISP Expiring Report.

PSU staff must upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff must document the HEART case record.
 

3210.3 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). MN exists when an individual, applicant or member meets the conditions described below:

  • The individual must demonstrate a medical condition that: 
    • is sufficient serious that the individual'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 individual must require medical or nursing services that: 
    • a physician orders; 
    • are dependent upon the individual'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.

PSU staff must refer to Section 3210.2, Reassessment of Medical Necessity Determination, for the information about MN redetermination procedures.

3300, Member Service Planning and Authorization

Revision 23-3; Effective May 22, 2023

The managed care organization (MCO) must collaborate with the member and legally authorized representative (LAR) to create and update Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, also known as the STAR Kids individual service plan (SK-ISP). The MCO develops the SK-ISP using a person-centered process with the support of a group of people chosen by the member or LAR. 

The purpose of the SK-ISP is to articulate assessment findings from the STAR Kids Screening and Assessment Instrument (SK-SAI). It includes short and long-term goals, service needs and member preferences. 

The MCO uses the SK-ISP for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the MCO; 
  • documenting services received through third-party sources; 
  • identifying a member's strengths, preferences, support needs, and desired outcomes; 
  • identifying what is essential to the member; 
  • identifying natural supports available to the member and needed supports; 
  • documenting the member's preferences for when and how to receive services; 
  • identifying special needs, requests, or considerations the MCO or providers should know when supporting the member; and 
  • documenting the member's unmet needs. 

The MCO must:

  • write the SK-ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language; 
  • submit the electronic SK-ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, as applicable; 
  • create and update the SK-ISP at least annually, as applicable; 
  • ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility; 
  • provide a printed or electronic copy of the SK-ISP to the member or LAR following any significant update; 
  • retain any amended SK-ISP in an MCO member's case file;
  • provide the Texas Health and Human Services Commission (HHSC) staff with the SK-ISP upon request; 
  • not provide significant change SK-ISPs to Program Support Unit (PSU) staff; and
  • authorize all services identified on the SK-ISP.

The SK-ISP must be within the member's cost limit. PSU staff must not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP 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.

3310 Service Planning

Revision 23-3; Effective May 22, 2023

Form 2603, STAR Kids Individual Service Plan (SK-ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and to develop the SK-ISP. The managed care organization (MCO) is responsible for completing Form 2603. The MCO maintains Form 2603 in the MCO's case file.

At a minimum, Form 2603 must account for the following information:

  • a summary document describing the recommended service needs identified through the SK-SAI;
  • covered services currently received;
  • covered services not currently received but the member may benefit from;
  • a description of non-covered services that could benefit the member;
  • member and family goals and service preferences;
  • natural strengths and supports of the member, including helpful family members, community supports or special capabilities;
  • a description of roles and responsibilities for the member, legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the MCO and the member's school with respect to maintaining and maximizing the health and well-being of the member;
  • a plan for coordinating and integrating care between providers and covered and non-covered services;
  • short and long-term goals for the member's health and well-being;
  • services provided to the member through other third-party resources (TPR) and the sources or providers of those services;
  • plans specifically related to transitioning to adulthood for members 15 and older;
  • a list of Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin and end date, and if the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable;
  • a brief rationale for the services; and
  • any other information to describe strategies to meet service objectives and member goals.

The MCO must include the items listed above in the SK-ISP.

3320 Service Planning for Medically Dependent Children Program Services

Revision 23-3; Effective May 22, 2023

The STAR Kids individual service plan (SK-ISP) contains a list of all the member's services, including Medically Dependent Children Program (MDCP) services. The managed care organization (MCO) lists MDCP services on Form 2603, STAR Kids Individual Service Plan Narrative. The list of MDCP services on Form 2603 must match the services listed on the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. 

The MCO must submit Form 2604 to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) before the start date of the member's SK-ISP following the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MCO must collaborate with the member or legally authorized representative (LAR) to create the SK-ISP including MDCP services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. Program Support Unit (PSU) staff will not calculate the SK-ISP cost limit. It is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field.

The MCO must initiate a reassessment for MDCP to determine and validate the need for continued services listed on the SK-ISP for each member before the end date of the annual STAR Kids Screening and Assessment Instrument (SK-SAI). The MCO must ensure all member reassessment activities, including submitting the SK-ISP to the TMHP LTCOP, are completed no earlier than 90 days and no later than 30 days before the expiration of the member's current SK-ISP on file. Failure to complete and submit timely reassessments may result in the member losing MDCP or Medicaid eligibility. 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 23-3; Effective May 22, 2023

It may be necessary for the managed care organization (MCO) to revise the STAR Kids individual service plan (SK-ISP) within the SK-ISP period due to situations outlined in the STAR Kids Contract, Section 8.1.39.1.

The MCO must retain the amended SK-ISP in the MCO's member case file. 

The MCO must not submit the revised SK-ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) or upload it to TxMedCentral.

3322 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

3323 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

3324 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022

 

3325 Reserved For Future Use

Revision 23-4; Effective Aug. 21, 2023

 

3326 Suspension of Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018

To remain eligible for Medically Dependent Children Program (MDCP) services, a member must receive one MDCP service monthly. In the event that the member travels out of state, is admitted to a hospital or nursing facility (NF), or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. The MCO must document the:

  • dates during which services are suspended; and
  • reason for suspension.

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in Section 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

3327 Reassessment Individual Service Plan Procedures

Revision 22-3; Effective Sept. 9, 2022

Program Support Unit (PSU) staff must ensure the member’s STAR Kids individual service plan (SK-ISP) is authorized annually. PSU staff must search the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for all SK-ISPs submitted on a daily basis. 

PSU staff must complete the following activities within five business days of receipt of the SK-ISP:

  • verify the member is under 21 in the Texas Integrated Eligibility Redesign System (TIERS);
  • verify the member is a Texas resident in TIERS;
  • check the TMHP LTCOP to determine if the managed care organization (MCO) has submitted the member’s SK-ISP before the SK-ISP end date;
  • verify the member has an approved medical necessity (MN) and STAR Kids Screening and Assessment Instrument (SK-SAI) in the TMHP LTCOP;
  • verify the member’s SK-ISP is within the cost limit;
  • confirm ongoing Medicaid financial eligibility and managed care enrollment is active in TIERS; 
  • verify the member has an SK-ISP with a least one Medically Dependent Children Program (MDCP) service;
  • upload 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; and 
  • document the HEART case record.

The member’s MDCP services will continue using the existing SK-ISP until a decision is received from the hearings officer if:

  • a member’s reassessment SK-ISP is developed; and
  • not submitted due to the member's timely appeal of an MDCP denial. 

PSU staff and the MCO coordinate the submission of a reassessment SK-ISP to ensure:

  • the SK-ISP records are correct; and 
  • the reassessment SK-ISP processes correctly once the state fair hearing decision is reached.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox each month. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs being reported as a MCO non-compliance. The subject line for the email must read: “MDCP Reassessment Delinquencies for [Month].” 

The assigned PSU staff is not required to send a follow up email to PSORT when the MCO submits the following documents for reassessment delinquencies:

  • Form H2067-MC, Managed Care Programs Communication; 
  • the SK-SAI; or 
  • the SK-ISP. 

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late reassessment activity. 

PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) on a monthly basis to ensure reassessments are conducted timely. The ISP Expiring Report details members with ISPs that expire within the next 90 days.

PSU staff will provide this report to the managed care organizations (MCOs) prior to the monthly call with PSU staff. The MCOs must provide a status update for all members who have ISPs expiring within the next 45 days. Although the ISP Expiring Report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update from the MCO.

The process for managing the ISP Expiring Report is as follows:

  • PSU staff provide the ISP Expiring Report to the MCO point of contact and to Managed Care Compliance & Operations (MCCO) staff by email five business days prior to the scheduled monthly call. The day of the call is not considered one of the business days.
  • The MCOs research and provide a written status for each member whose ISP expires within 45 days, completing the columns highlighted in red on the spreadsheet.
  • The MCO must return a completed report to PSU staff within two business days prior to the monthly call.
  • PSU staff review the MCO responses to determine if the MCO needs to provide clarification regarding any member’s ISP status. During the monthly call, only ISP statuses about which PSU staff have questions are reviewed. There is no need to review each member for the status of the ISP if the MCO response is sufficient. PSU staff use the columns in blue on the spreadsheet for internal tracking purposes.

Note: There will not be a need to review each member for the status of the ISP if the MCO response is sufficient.

3328 Reassessment Notification Requirements

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, at reassessment as notification of continuing Medically Dependent Children Program (MDCP) eligibility if the member meets MDCP requirements. 

PSU staff must complete the following activities for an approved MDCP reassessment within five business days from verification that the member continues to meet all MDCP requirements:

  • electronically generate Form H2065-D in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • mail Form H2065-D to the member, legally authorized representative (LAR) or medical consenter; 
  • 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; and 
  • document and close the HEART case record.

Refer to Section 6000, Denials and Terminations, if the member does not meet MDCP requirements at reassessment.

Refer to Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, if the member, LAR or medical consenter files a state fair hearing within the adverse action notification time period.

Refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements regarding the termination of MDCP for STAR Health members.

3400, Member Transfers

3410 Transfer from One MCO to Another

Revision 22-3; Effective Sept. 9, 2022

A member or legally authorized representative (LAR) can request to change managed care organization (MCO) plans as often as they want, but the change cannot be made more than once per month. A member can only be enrolled with one MCO for a given month.  
A member or LAR who wants to change from one MCO to another MCO must contact the state-contracted enrollment broker by: 

  • phone: 800-964-2777;
  • fax: 855-671-6038; or
  • mail: 
    HHSC 
    P.O. Box 149023 
    Austin TX 78714-9023

Note: Adoption Assistance or Permanency Care Assistance (AAPCA) members must contact the state’s enrollment broker to request transfer.

MCO enrollment changes become effective based on the date the MCO change is requested and processed in relation to state cutoff. 

Refer to Appendix XIV, State Cutoff Charts, for more information on for additional information on current cutoff dates.

Monthly Plan Changes Report

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. The report gives a full list of all Medically Dependent Children Program (MDCP) members who have changed MCOs from the previous month. PSU staff are not required to provide the Plan Change Report to the MCOs. MCOs receive the plan change report for their members only through an automated process in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal (LTCOP).

The losing MCO and the gaining MCO must coordinate and share applicable member information in order to prevent a gap in services during the transfer. In cases where this does not occur, the HHSC Managed Care Contracts and Oversight (MCCO) Unit staff must request PSU staff intervention. Within two business days of notification from MCCO Unit staff, PSU staff must assist with the transfer of information from the losing MCO to the gaining MCO.

The gaining MCO will have access to current and historical STAR Kids Screening and Assessment Instruments (SK-SAIs) and STAR Kids - Individual Service Plans (SK-ISPs) in the TMHP LTCOP once the member is enrolled with them. 
The gaining MCO is responsible for service delivery from the first day of enrollment. The gaining MCO must provide services and honor authorizations included in the prior SK-ISP until the member receives a new SK-SAI. 

3420 Transfer from Another Medicaid Waiver Program to Medically Dependent Children Program

Revision 21-10; Effective October 25, 2021

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 Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by a member.

Individuals in the following Intellectual and Developmental Disabilities (IDD) waiver programs may be on the interest list for MDCP:

  • Community Living Assistance and Support Services (CLASS);
  • Home and Community-based Services (HCS);
  • Deaf Blind with Multiple Disabilities (DBMD); or
  • Texas Home Living (TxHmL).

Program Support Unit (PSU) staff will receive a Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) interest list release (ILR) case record assignment from Interest List Management (ILM) Unit staff when an individual in another IDD waiver program comes to the top of the MDCP interest list and requests MDCP. PSU staff may also receive notification from IDD waiver program staff.

PSU staff must complete the following activities within three business days of the receipt of the MDCP ILR case record assignment in HEART or notification from IDD waiver program staff:

  • Create a case record in HEART, if applicable;
  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid eligibility;
  • Verify that individual has an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the TxHmL or HCS waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the CLASS (Service Group 2) and DBMD (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
    • Form 2600-B, MDCP Waiver Release Letter - Supplemental Security Income;
    • Form 2602 , Application Acknowledgement;
    • Appendix IV, MDCP Frequently Asked Questions;
    • Appendix XX, MDCP Program Description; and
    • a postage-paid envelope.

PSU staff must contact the individual or LAR within 14 days from the mail date of the above enrollment packet to:

  • Verify receipt of the enrollment packet;
  • Confirm interest in MDCP;
  • Give a general description of MDCP services; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual or LAR did not express interest in MDCP.

PSU staff can accept the individual’s or LAR’s verbal statement of interest in MDCP. PSU staff must document all attempted contacts with the individual, LAR and IDD waiver program staff and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual or LAR does not have an interest in pursuing MDCP services.

PSU staff must contact the individual or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain confirmed interest in MDCP, if PSU have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect; and
  • Encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual or LAR does not express interest in MDCP.

PSU must document all contact attempts in the HEART case record.

The individual or LAR is not required to select a managed care organization (MCO) since the individual is already enrolled with a STAR Kids MCO. PSU staff can accept the individual or LAR’s verbal statement of interest in MDCP.

PSU staff must complete the following activities within two business days from the date the individual or LAR expressed interest in MDCP:

  • Complete Form H3676 , Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document the HEART case record.

The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) within a total of 30 days from the date PSU staff uploaded Form H3676, Section A to TxMedCentral. The SK-SAI is considered “complete” when the MCO has obtained a physician’s signature on Form 2601, Physician’s Certification.

The MCO must submit the complete SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within a total of 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral. PSU staff must monitor the TMHP LTCOP for receipt of the completed SK-SAI.

The MCO must submit the following documents within a total of 60 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral:

  • The STAR Kids Individual Service Plan (SK-ISP) to the TMHP LTCOP; and
  • Form H3676, Section B to TxMedCentral.

PSU staff must monitor TxMedCentral for receipt of Form H3676, Section B. PSU staff must monitor the TMHP LTCOP for receipt of the SK-ISP.

PSU staff must email Managed Care Compliance & Operations (MCCO) Unit staff at PSU_Past_Due_Assessments@hhsc.state.tx.us to advise if the MCO has not completed and submitted the following items within 60 days of the date of PSU staff uploaded Form H3676, Section A, to TxMedCentral:

  • The completed SK-SAI;
  • The completed SK-ISP or
  • Form H3676, Section B.

PSU staff must contact and coordinate with IDD waiver program staff, the applicant, LAR and MCO as appropriate, ensuring the applicant’s current Medicaid waiver program services end one day before enrollment in MDCP.

PSU staff must complete the following activities within two business days of receipt of all required MDCP eligibility documentation:

  • Confirm MDCP eligibility by verifying the applicant:
    • is under age 21 in TIERS;
    • is a Texas resident in TIERS;
    • has a compatible Medicaid eligibility for MDCP in TIERS;
    • has an approved medical necessity (MN) in the TMHP LTCOP;
    • has an SK-ISP with a least one MDCP service; and
    • has an SK-ISP within the applicant’s cost limit.

PSU staff must approve the applicant’s enrollment in MDCP the first day of the following month after verifying all MDCP eligibility criteria are met. PSU staff must complete the following activities within two business days of determining the start of care (SOC) date for MDCP:

  • Generate Form H2065-D, Notification of Managed Care Program Services, following the instructions Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, in the TMHP LTCOP;
  • Mail Form H2065-D to the member or LAR;
  • Email Enrollment Resolution Services (ERS) Unit at ManagedCareEligibilityEnrollment@hhsc.state.tx.us. The email to the ERS Unit must include the following information:
    • an email subject line that reads: “Waiver Transfer for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for a waiver transfer for Ann Smith would be “Waiver Transfer for ANN.SMI”;
    • member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., waiver transfer);
    • MN approval date;
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO;
    • effective date of enrollment; and
    • Form H2065-D; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII;
  • Document all contacts with the IDD waiver program staff, member, LAR or MCO and any delays; and
  • Close the HEART record.

PSU staff must complete the following activities for an individual whose MDCP eligibility is denied or who declined MDCP:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, notifying the MCO that the individual is not eligible for MDCP;
  • Upload all applicable documents to the HEART case record. following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

The MCO must upload Form H3676, Section B, to TxMedCentral within two business days if the applicant fails to meet any MDCP eligibility criteria other than Medicaid financial eligibility. PSU staff must complete the following activities for an applicant whose MDCP eligibility is denied or who declined MDCP:

  • Electronically generate Form H2065-D if the applicant is denied due to not meeting MN;
  • Manually generate Form H2065-D if the applicant is denied for reasons other than MN;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral if manually generated;
  • Fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist for medical assistance only (MAO) members;
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • Document and close the HEART case record. 

3430 Transfer from MDCP to Another Medicaid Waiver Program

Revision 23-4; Effective Aug. 21, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1155(b)(1)(F) states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one Medicaid waiver program at the same time. Refer to Appendix XIX, Mutually Exclusive Services, to determine if a member may receive two services simultaneously.
MDCP members may be on an interest list for an Intellectual and Developmental Disabilities (IDD) waiver program, such as:

  • Community Living Assistance and Support Services (CLASS);
  • Home and Community-based Services (HCS);
  • Deaf Blind with Multiple Disabilities (DBMD); or
  • Texas Home Living (TxHmL).

Program Support Unit (PSU) may receive notification from IDD waiver program staff or the MDCP member’s managed care organization (MCO) that the MDCP member:

  • has come to the top of an IDD waiver program interest list;
  • chooses to transfer to the IDD wavier program; or
  • is already enrolled with an IDD waiver program.

PSU staff must complete the following activities within three business days from notification:

  • create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART), if applicable;
  • contact and coordinate with IDD waiver program staff by email to determine an MDCP termination date and a start of care (SOC) date for the IDD waiver program;
    • The MDCP termination date must be the last day of the month before the IDD waiver SOC date.
  • terminate the STAR Kids Individual Service Plan (SK-ISP) and the Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to the last day of the month before the IDD waiver SOC date. 
  • manually generate Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to TxMedCentral;
  • mail Form H2065-D to the member, legally authorized representative (LAR) or medical consenter;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the MDCP termination date and the enrollment effective date for the new Medicaid waiver program; 
  • upload all applicable documents to the HEART case record;
  • document all contacts with the IDD waiver program staff, member, LAR, medical consenter or MCO and any delays; and
  • close the HEART case record. 

3440 Transfer from Community Care for Aged and Disabled Services to STAR Kids

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must coordinate the termination of Community Care for Aged and Disabled (CCAD) services with the CCAD case worker so the individual does not experience a break in services and does not receive concurrent services through another §1915(c) Medicaid waiver or CCAD.

For individuals entering STAR Kids through the Medically Dependent Children Program (MDCP), PSU staff coordinate the termination of CCAD services with the §1915(c) Medicaid waiver or CCAD case worker. This ensures the individual does not experience a break in services and does not receive concurrent services through CCAD services.

CCAD services are terminated by the CCAD case worker no later than the day prior to MDCP enrollment. This is crucial since no MDCP member may receive CCAD and MDCP services on the same day.

3500, Transition from Medically Dependent Children Program to Adult Programs

Revision 23-3; Effective May 22, 2023

All STAR Kids members begin transition activities at age 15 and periodically meet with a transition specialist to plan their transition to an adult program.

A person receiving Medically Dependent Children Program (MDCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC): 

  • is no longer eligible for these services at 21 years old; 
  • must transition to an adult program; and
  • may choose to transition to the STAR+PLUS Home and Community Based Services (HCBS) program.

Each quarter, Texas Health and Human Services Commission (HHSC) Utilization Review (UR) provides a copy of the MDCP PDN Transition Report to: 

  • Program Support Unit (PSU) supervisors and managers; and
  • UR unit for the Intellectual and Developmental Disability (IDD) 1915(c) waivers.

The report lists members enrolled in STAR Kids: 

  • receiving MDCP, PDN or PPECC services; and
  • who may transition to STAR+PLUS or the STAR+PLUS HCBS program in the next 12 months.

PSU staff must refer to Appendix VI, STAR Kids Transition Activities, for more information about managing this report, including time frames.

3510 Twelve Months Before the Member's 21st Birthday

Revision 23-3; Effective May 22, 2023

The member’s STAR Kids managed care organization (MCO) identifies all members turning age 21 within the 12 months before the member's 21st birthday. The STAR Kids MCO schedules a face-to-face visit with the member and the member's available supports to initiate the transition process to:

  • provide an overview of the STAR+PLUS Home and Community Based Services (HCBS) program; and
  • discuss the changes that will occur in the first month following the member's 21st birthday.

The STAR Kids MCO follows up with the member or legally authorized representative (LAR) every 90 days during the year before the member turns 21. This is to ensure the MCO completes all transition activities.

The enrollment broker (EB) will contact the member 30 days before the member’s 21st birthday and mail the STAR+PLUS HCBS enrollment packet. EB will select an MCO for the member if no selection has been made within 15 days, as outlined in Title 1 Texas Administrative Code (TAC) Section 353.403(3).  

The member’s selected or defaulted STAR+PLUS MCO conducts the Medical Necessity and Level of Care (MN/LOC) Assessment for those receiving the Medically Dependent Children Program (MDCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) to determine eligibility for the STAR+PLUS HCBS program before 21.

Members who meet the STAR+PLUS HCBS program enrollment criteria will transition to the STAR+PLUS HCBS program on the first of the month following their 21st birthday. MDCP eligibility terminates on the last day of the month when the member's 21st birthday occurs.

Program Support Unit (PSU) staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for PSU staff denial procedures for MDCP members transitioning out of MDCP due to turning 21.

PSU staff must refer to the following resources for more detailed information about STAR Kids transition activities, as applicable: 

  • Appendix VI, STAR Kids Transition Activities;
  • the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH); and 
  • the STAR+PLUS Handbook (SPH). 

3520 Transition Policy for Non-Waiver Individuals and Applicants Receiving PCS or CFC Only

Revision 21-10; Effective October 25, 2021

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the non-waiver program individual’s or applicant’s 21st birthday occurs. The non-waiver program individual or applicant with STAR Kids or STAR Health must receive services through programs serving adults beginning the first day of the month following the non-waiver program individual’s or applicant’s 21st birthday.

Individuals or applicants with STAR Kids and STAR Health must transition their Personal Care Services (PCS) and Community First Choice (CFC) services to an adult program. Some individuals or applicants with STAR Kids and STAR Health may continue to receive PCS or CFC through STAR Health until age 22 depending on eligibility requirements.

The Texas Health and Human Services Commission’s (HHSC’s) state contracted enrollment broker will reach out to the individual or applicant 30 days prior to the individual’s or applicant’s 21st birthday and provide the individual or applicant with a STAR+PLUS enrollment packet. The individual or applicant is allowed 15 days to make a managed care organization (MCO) selection. HHSC’s contracted enrollment broker will select an MCO for the individual or applicant if the individual or applicant has not made an MCO selection after 15 days, as outlined in Title 1 Texas Administrative Code (TAC) §353.403(3).

4000, STAR Kids Community Services

4010 Outline

Revision 22-3; Effective Sept. 9, 2022

This section outlines the delivery of STAR Kids community long term services and supports (LTSS). Sections 4100 – 4100.5 describe Medicaid state plan services available to STAR Kids members who have an assessed need as identified by the STAR Kids Screening and Assessment Instrument (SK-SAI).

Sections 4200 – 4200.8 describe services available to members receiving Medically Dependent Children Program (MDCP).

4100, Medicaid State Plan Services for STAR Kids Members

4100.1 Community First Choice

Revision 22-3; Effective Sept. 9, 2022 

Community First Choice (CFC) is available to all STAR Kids members who meet an institutional level of care (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. CFC services include personal care services (CFC-PCS), Emergency Response Services (CFC-ERS), support management, and habilitation (CFC-HAB). 

The managed care organization (MCO) must ensure the member receives at least one waiver service per month to maintain CFC eligibility. 

CFC-PCS provides help with activities of daily living (ADLs), instrumental activities of daily living (IADLs) through hands-on assistance, supervision, cueing or both, to include nurse-delegated tasks. Members may not be authorized for State Plan PCS and CFC-PCS at the same time. 

CFC-HAB provides assistance with acquisition, maintenance, and enhancement of skills necessary for the member to accomplish ADLS, IADLs and health-related tasks. 

CFC-ERS provides assistance for members who live alone, are alone for large parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. This service connects a member to an emergency response services (ERS) provider who notifies local authorities, like paramedics of a member's emergency. 

CFC support management provides voluntary training on how to select, manage and dismiss attendants. 

Refer to the STAR Kids Handbook (SKH) for more information about CFC services. 

4100.2 Personal Care Services

Revision 22-3; Effective Sept. 9, 2022 

Personal Care Services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP).

PCS provides help 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. 

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time. 

Refer to the STAR Kids Handbook (SKH) for more information about PCS. 

4100.3 Private Duty Nursing

Revision 22-3; Effective Sept. 9, 2022

Private duty nursing (PDN) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP).

PDN is nursing services for members who:

  • meet medical necessity (MN) criteria outlined in the STAR Kids Screening and Assessment Instrument (SK-SAI); and
  • require individualized, continuous skilled care beyond the level of skilled nursing visits provided under Texas Medicaid home health services. 

Refer to the STAR Kids Handbook (SKH) for more information about PDN. 

4100.4 Prescribed Pediatric Extended Care Centers

Revision 22-3; Effective Sept. 9, 2022 

Prescribed Pediatric Extended Care Center (PPECC) services is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Comprehensive Care Program (CCP), known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). 

PPECC is a facility that provides nonresidential basic services, including medical, nursing, psychosocial, therapeutic, and developmental services to medically dependent or technologically dependent members under 21 years for up to 12 hours per day. 

Refer to the STAR Kids Handbook (SKH) for more information about PPECC. 

4100.5 Day Activity and Health Services

Revision 22-3; Effective Sept. 9, 2022 

Day activity health services (DAHS) for members 18 through 20. DAHS includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services.

Refer to the STAR Kids Handbook (SKH) for more information about DAHS.

4200, Medically Dependent Children Program Services

Revision 22-3; Effective Sept. 9, 2022 

The Medically Dependent Children Program (MDCP) is a 1915(c)-waiver program for eligible members. It prevents placement in long-term care facilities who are medically dependent and under 21 years old. Only members who are assessed as meeting medical necessity (MN) for Medically Dependent Children Program (MDCP) and who have a slot in MDCP are eligible for MDCP services.

The applicant or member’s managed care organization (MCO) uses the STAR Kids Screening and Assessment Instrument (SK-SAI) to assess for MN for MDCP. Receipt of MDCP services does not impact a member's eligibility for other long-term services and supports (LTSS) available in STAR Kids. Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

MDCP services include respite, flexible family support services (FFSS), minor home modifications, adaptive aids, transition assistance services (TAS), supported employment (SE), employment assistance (EA) and financial management services (FMS).

4200.1 Medically Dependent Children Program Respite

Revision 22-3; Effective Sept. 9, 2022 

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.

Refer to the STAR Kids Handbook (SKH) for more information about respite services.

4200.2 Flexible Family Support Services

Revision 22-3; Effective Sept. 9, 2022 

Flexible family support services (FFSS) are direct care services needed because of a member's disability that help a member participate in childcare, post-secondary education, employment, independent living, or support a member's move to an independent living situation. 

Refer to the STAR Kids Handbook (SKH) for more information about flexible family support services.

4200.3 Adaptive Aids

Revision 22-3; Effective Sept. 9, 2022

Adaptive aids are devices necessary to treat, rehabilitate, prevent, or compensate for conditions resulting in disability or loss of function and enable members to:

  • perform activities of daily living (ADL); or
  • control the environment in which they live.

Adaptive aids are available through the Medically Dependent Children Program (MDCP), if:

  • determined medically necessary; and
  • only after exhausting all Medicaid state plan services and other third-party resources.

After any applicable benefits are exhausted, adaptive aids covered through MDCP include but are not limited to:

  • van lifts;
  • vehicle modifications;
  • jump seats;
  • tumble form chairs;
  • feeder seats;
  • medically appropriate strollers;
  • barrier-free lifts;
  • stair lifts;
  • environmental control units;
  • alarm systems;
  • support rails;
  • electrical work related to use of authorized adaptive aids;
  • installation of authorized adaptive aids; and
  • repairs to adaptive aids. 

Refer to the STAR Kids Handbook (SKH) for more information about adaptive aids.

4200.4 Minor Home Modifications

Revision 22-3; Effective Sept. 9, 2022

A minor home modification (MHM) is a physical modification to a member’s residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare, and safety of the member or to enable the member to function with greater independence in their home. 

Refer to the STAR Kids Handbook (SKH) for more information about minor home modifications.

4200.5 Transition Assistance Services

Revision 22-3; Effective Sept. 9, 2022

Transition assistance services (TAS) are a one-time service provided to a Medicaid-eligible resident of a nursing facility (NF) located in Texas to assist the resident in moving from the NF into the community to receive Medically Dependent Children Program (MDCP) services.

Refer to the STAR Kids Handbook (SKH) for more information about TAS.

4200.6 Employment Assistance

Revision 22-3; Effective Sept. 9, 2022 

Employment assistance (EA) helps a member locate paid employment in the community. EA services include:

  • identifying a member’s employment preferences, job skills, and requirements for a work setting and work conditions;
  • locating prospective employers offering employment compatible with a member’s identified preferences, skills, and requirements; and
  • contacting a prospective employer on behalf of a member and negotiating the member’s employment.

Refer to the STAR Kids Handbook (SKH) for more information about EA. 

4200.7 Supported Employment

Revision 22-3; Effective Sept. 9, 2022 

Supported employment (SE) helps 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 where members without disabilities are employed. SE services include:

  • assistance provided to a member to sustain competitive employment and who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting at which individuals without disabilities are employed;
  • employment adaptations, supervision and training related to a member’s assessed need; and
  • ensuring members earn at least minimum wage, if not self-employed.

Refer to the STAR Kids Handbook (SKH) for more information about SE.

4200.8 Financial Management Services (FMS)

Revision 22-3; Effective Sept. 9, 2022 

Financial management services (FMS) are available to members who choose the Consumer Directed Services (CDS) option. FMS helps members with managing funds related to the services elected for self-direction. The service includes initial orientation and ongoing training about responsibilities of being an employer and adhering to legal requirements for employers. 

Refer to the STAR Kids Handbook (SKH) for more information about FMS.

6100, Description

Revision 22-1; Effective January 31, 2022

This section contains policy for Program Support Unit (PSU) staff when processing:

  • case closure for an individual applying for the Medically Dependent Children Program (MDCP);
  • denials and terminations for an applicant or member; and
  • information regarding adequate notice of an applicant’s or member’s right to due process.

PSU staff must mail Form 2442, Notification of Interest List Release Closure, as notification of an MDCP interest list closure to an individual when the individual does not meet MDCP eligibility. PSU staff must always mail Form 2442 with Appendix XX, MDCP Program Description. Form 2442 does not provide the right to request a state fair hearing. An individual will only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff must mail an applicant or member Form H2065-D when the applicant or member is denied or terminated from MDCP. Form H2065-D provides an applicant or member with the right to request a state fair hearing. An applicant or member will never receive Form 2442.

Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), provides the rules for adverse action for members required by Title 42 Code of Federal Regulations (CFR) Part 431, Subpart E, including requiring that: 

  • the written notice to the member of their right to a hearing must:
    • contain an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and 
    • be delivered by mail, and postmarked at least 10 business days, before the date the member’s Medicaid eligibility or service is scheduled to be terminated, suspended or reduced, except as provided by Title 42 CFR §431.213 or Title 42 CFR §431.214; and
  • if a hearing is requested before the date a member’s service, including a service that requires prior authorization, is scheduled to be terminated, suspended or reduced, Texas Health and Human Services Commission (HHSC) may not take that proposed action before a decision is rendered after the hearing unless: 
    • it is determined at the hearing that the sole issue is one of federal or state law or policy; and
    • the agency promptly informs the recipient in writing that services are to be terminated, suspended or reduced pending the hearing decision.

Title 42 CFR Part 431, Subpart E, governs fair hearing rights for Medicaid individuals, applicants and members. However, Title 42 CFR §431.213 specifies situations where an adverse action notification period is not required. The agency may mail a notice not later than the date of action if:

  • The agency has factual information confirming the death of an individual, applicant or member; 
  • The agency receives a clear written statement signed by a member that:
    • they no longer want to receive services; or
    • gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information; and
  • The individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
  • The individual’s, applicant’s or member’s whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address (See Title 42 CFR §431.231(d) of this subpart for procedure if the individual’s, applicant’s or member’s whereabouts become known);
  • The agency establishes the fact that the individual, applicant or member has been accepted for Medicaid services by another local jurisdiction, state, territory or commonwealth;
  • A change in the level of medical care is prescribed by the applicant’s or member’s physician; 
  • The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or
  • The date of action will occur in less than 10 days, in accordance with Title 42 CFR §483.15(b)(4)(ii) and (b)(8), which provides exceptions to the 30 days’ notice requirements of Title 42 CFR §483.15(b)(4)(i) of this chapter.

6110 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);
  • need at least one MDCP service not being addressed by other 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.

6110.1 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; 
  • live 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): 
  • Community Living Assistance and Support Services (CLASS) Program; 
  • Deaf Blind with Multiple Disabilities (DBMD) Program; 
  • Home and Community-based Services (HCS) Program; 
  • Texas Home Living (TxHmL) Program; or 
  • Youth Empowerment Services waiver; 
  • live in: 
  • the person's home; or 
  • an agency foster home as defined in Texas Human Resource Code, Section 42.002, (relating to Definitions); and 
  • 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 is approved for MDCP if the applicant:

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

6200, Adverse Action Notification Period

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, to the member no later than 12 business days before the termination effective date. This requirement ensures:

  • the member maintains services while Form H2065-D travels through the mail; and
  • the member has enough time to request a state fair hearing with the option of maintaining continued Medically Dependent Children Program (MDCP) services until a state fair hearing decision is rendered. 

Day zero is the day PSU staff mail Form H2065-D to the member.

The MDCP termination dates are typically on the last day of the month. PSU staff must manually extend the individual service plan (ISP) record’s end date in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to the last day of the following month if:

  • the 12th business day is beyond the current ISP end date; and
  • the adverse action notification period applies.

See the example chart below for further clarification.

Example Chart:

Form H2065-D SentOriginal ISP End DateAdverse Action Expiration Date: 12th Business DayExtend ISP in TMHP LTCOP for Adverse ActionForm H2065-D Termination DateMember Requests State Fair HearingServices Continue During State Fair Hearing?
6/12/207/31/206/30/20No7/31/207/15/20Yes
6/1/206/30/206/17/20No6/30/207/2/20No
6/25/206/30/207/13/20Yes7/31/207/17/20Yes
6/25/206/30/207/13/20Yes7/31/207/13/20Yes
8/28/208/31/209/15/20Yes9/30/209/14/20Yes

The adverse action notification period does not apply to all member terminations. The adverse action notification period does not apply when: 

  • PSU staff has factual information confirming the death of a member;
  • the member submits a signed written statement waiving their right to the adverse action notification period and understands their services will end;
  • the member is denied Medicaid financial eligibility for MDCP;
  • the member is admitted to an institution for 90 consecutive days where MDCP services cannot be delivered;
  • the member accepts Medicaid services by another jurisdiction, state, territory or commonwealth; or
  • the member chooses to enroll in another Medicaid waiver program. 

6300, Denials and Terminations

Revision 22-1; Effective January 31, 2022

The following sections contain Program Support Unit (PSU) staff procedures for individual case closures, applicant denials and member terminations.

6300.1 Death

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility upon verification an applicant or member is deceased.

PSU staff must process a case closure upon notification that an individual is deceased. PSU staff may receive notification of the individual’s, applicant’s or member’s date of death by:

  • Managed Care Operations;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the legally authorized representative (LAR) or family member;
  • the managed care organization (MCO); or
  • other reliable sources.

PSU staff must verify the individual’s, applicant’s or member’s death in the Texas Integrated Eligibility Redesign System (TIERS). There may be instances where an individual, applicant or member is deceased and information is not updated in TIERS. In those instances, PSU staff must receive verification of death from other sources.

PSU staff must complete the following activities for individuals within two business days of verification of death:

  • upload Form H2067-MC, Managed Care Programs Communication (PDF), to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO of the individual’s date of death and case closure, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of verification of death:

  • upload Form H2067-MC (PDF) to TxMedCentral following the instructions in Appendix IX notifying the MCO of the applicant’s date of death and case closure, if applicable;
  • document and close the CSIL record, if applicable;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and People with Disabilities (MEPD) specialist if TIERS does not show the applicant is deceased;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of verification of death:

  • upload Form H2067-MC to TxMedCentral following the instructions in Appendix IX notifying the MCO of the member’s date of death and case closure, if applicable;
  • for MAO members, fax Form H1746-A following the instructions in Appendix XV to the MEPD specialist if TIERS does not show the member is deceased;
  • adjust the ISP end date to the date of death and terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload the applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must not mail Form 2442, Notification of Interest List Release Closure (PDF), or Form H2065-D, Notification of Managed Care Services (PDF), to the individual’s, applicant’s, member’s, LAR’s or family’s address, if applicable. The applicant’s or member’s denial or termination effective date is the date of death and may be a mid-month date.

Example: PSU staff receive notification from the MEPD specialist that the member passed away on 7/26/2021. The member’s termination effective date is 7/26/2021.

The adverse action notification period does not apply in this situation.

6300.2 Living Arrangement is Not an Allowable Setting

Revision 22-3; Effective Sept. 9, 2022

Title 42 CFR Section 441.301(c)(5) states the following living arrangements are not an allowable setting for the receipt of the Medically Dependent Children Program (MDCP):

  • a nursing facility (NF);
  • an institution for mental diseases;
  • an intermediate care facility for people with intellectual disabilities;
  • a hospital;
  • any other location that has qualities of an institutional setting, as determined by the U.S. Department of Health and Human Services (HHS) Secretary; or
  • any setting located in a building that is also a publicly or privately operated facility providing inpatient institutional treatment; or 
  • in a building or any other setting:
    • on the grounds of; or
    • immediately next to a public institution that:
      • has the effect of isolating people receiving Medicaid Home and Community Based Services (HCBS) from the broader community of people not receiving Medicaid HCBS;
        • unless the HHS Secretary determines through heightened scrutiny, based on information presented by the state or other parties, that the setting does:
          • not have the qualities of an institution; and 
          • have the qualities of home and community-based settings. 

PSU staff may receive notification of the applicant or member’s living arrangement by:

  • managed care operations;
  • enrollment resolution services (ERS) Unit staff;
  • applicant, member, legally authorized representative (LAR) or family member;
  • managed care organization (MCO); or
  • other reliable sources.

Program Support Unit (PSU) staff must deny or terminate MDCP eligibility when an applicant or member has not returned to an allowable living arrangement by the 90th day. 

The MCO will notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication (PDF), to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, within 14 days following the 90th day that the applicant or member has not returned to an allowable living arrangement. 

PSU staff must email the Managed Care Contracts and Oversight (MCCO) Unit advising that the MCO is not timely in their notification if the MCO fails to meet this notification time frame.

PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must deny the applicant by the end of the month in which the 90th day occurred within two business days of notification by:

  • manually generating Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
    • Note: refer to Form H2065-D instructions for additional information on field entries;
  • mailing Form H2065-D to the applicant or LAR;
  • uploading Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) Medicaid applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • documenting and closing the Community Services Interest List (CSIL) database record, if applicable;
  • invalidating the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • uploading applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • documenting and closing the HEART case record.

Note: Refer to Section 2412.5, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials, and Section 2413.5, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials, for additional information related to applicants pursing MDCP though the traditional Money Follows the Person (MFP) process.

PSU staff must terminate the member by the end of the month in which the 90th day occurred within two business days of notification by:

  • manually generating Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
    • Note: refer to Form H2065-D instructions for more information on field entries;
  • mailing Form H2065-D to the member or LAR;
  • uploading Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjusting the SK-ISP end date to the termination effective date in the TMHP LTCOP and terminating the SK-ISP record, following the instructions listed in Appendix I;
  • for MAO Medicaid members, complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • for MAO Medicaid members, email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a MDCP termination for Ann Smith would be “MDCP Termination for AS”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (e.g., MDCP eligibility termination);
    • SK-ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

An applicant or member denied or terminated due to an extended stay in a nursing facility (NF) may pursue the Money Follows the Person (MFP) process to reapply for MDCP and return to the community with services. Refer to Section 2400, Money Follows the Person, for procedures for the traditional MFP process and to Section 2420, Money Follows the Person Limited NF Stay Options for Medically Fragile Individual, for procedures for the nursing facility limited stay process.

The process for applicants and members residing in Truman Smith is not applicable to this section. An applicant or member enrolled in STAR Kids who enters the Truman Smith NF or a state veteran’s home is excluded from STAR Kids. STAR Kids and MDCP eligibility must be denied or terminated, as applicable.

The adverse action notification period does not apply in this situation.

6300.3 Voluntarily Declined Services

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when notified an applicant or member no longer wants to receive MDCP services. PSU staff must process a case closure upon notification that an individual voluntarily declines services.

PSU staff may receive notification of the individual’s, applicant’s, member’s or legally authorized representative’s (LAR’s) request to voluntarily decline MDCP from:

  • Managed Care Operations;
  • receipt of Form 2602, Application Acknowledgment (PDF), indicating no interest in MDCP;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the individual, applicant, member or LAR;
  • the managed care organization (MCO); or
  • other reliable sources.

PSU staff must complete the following activities for individuals within two business days of notification:

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet (PDF), following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the CSIL record, if applicable;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP.

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for a MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must:

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

Note: See the Uniform Managed Care Manual (UMCM) Chapter 16.2 for procedures for STAR Health individuals.

The medical consenter appointed by the Department of Family and Protective Services (DFPS) is the only person who can accept or decline to pursue MDCP on behalf of the individual, applicant or member.

Per Title 4 Texas Government Code, Subtitle I, Chapter 531, Subchapter A, Section 531.024 (2)(b)(1)(A), the adverse action notification period applies in this situation unless PSU staff receive a clear written statement signed by the member or LAR indicating that the member no longer wants to receive services. The termination effective date is the last day of the current month if the adverse action notification period is waived.

Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.4 Financial Eligibility

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not meet Medicaid financial eligibility. An applicant’s or member’s Medicaid financial eligibility for MDCP is determined by the: 

  • Social Security Administration (SSA) for Supplemental Security Income (SSI) recipients; or 
  • Medicaid for the Elderly and People with Disabilities (MEPD) specialist for:
    • medical assistance only (MAO) Medicaid recipients; or
    • SSI-related Medicaid recipients such as applicants or members who receive:
      • ME-Pickle; or
      • ME-Disabled Adult Child.

The applicant or member may appeal a Medicaid financial denial using SSA or the MEPD fair hearing process, as appropriate.

PSU staff may receive notification of the denial or termination of an applicant or member’s Medicaid financial eligibility from the:

  • Texas Integrated Eligibility Redesign System (TIERS);
  • monthly loss of eligibility (LOE) reports;
  • MEPD specialist; 
  • Enrollment Resolution Services (ERS) Unit;
  • managed care organization (MCO); or
  • other reliable sources.

PSU staff must complete the following activities for applicants within two business days of the denial notification:

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, if applicable;
  • verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
  • manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail the following forms to the applicant or legally authorized representative (LAR): 
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • document and close the Community Services Interest List (CSIL) database record, if applicable;
  • invalidate the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record. 

Note: Refer to Section 2412.5, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials, and Section 2413.5, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials, for additional information related to applicants pursing MDCP though the traditional Money Follows the Person (MFP) process.

PSU staff must complete the following activities for members within two business days of notification of termination:

  • create a new HEART case record, if applicable;
  • verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail the following forms to the member or LAR: 
    • Form H2065-D;
    • Form H1200; and
    • Form 2606; 
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the SK-ISP end date to the Medicaid financial termination date in the TMHP LTCOP, following the instructions in Appendix I;
  • terminate the SK-ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record.

The termination effective date in the TMHP LTCOP must match the TIERS Medicaid/CHIP/CHIP Perinatal History screen end date. This is true even if the TIERS end date is in the past.

The table below depicts examples of PSU staff actions when the MEPD specialist determines a member no longer meets Medicaid financial eligibility.

TIERS Date for Loss of Financial EligibilityDate PSU Informed Eligibility LostCurrent TMHP LTCOP SK-ISP End DateDate Form H2065-D SentForm H2065-D Termination DateTMHP LTCOP Data Entry
12-31-201612-31-20165-31-20171-2-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.
12-31-20161-15-20171-31-20171-17-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.
12-31-20162-5-20175-31-20172-7-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.
12-31-20166-5-20175-31-20176-7-201712-31-2016SK-ISP end date must be corrected to 12-31-2016.

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a state fair hearing prior to the termination effective date.

Notes:

  • The member can resume services if Medicaid financial eligibility is reestablished with a gap of six months or less. The MCO may use the existing SK-ISP and STAR Kids Screening and Assessment Instrument (SK-SAI) if they are still valid. The MCO must conduct a reassessment without penalty if the SK-ISP and medical necessity (MN) have expired.
  • The member must go to the bottom of the interest list to reapply for services if Medicaid financial eligibility is reestablished with a gap greater than six months.

6300.5 Medical Necessity and Level of Care

Revision 22-1; Effective January 31, 2022

Title 26 TAC Section 554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the Medically Dependent Children Program (MDCP). To verify MN exists, an applicant or member must meet the following conditions described below:

  • The applicant or member must demonstrate a medical condition that: 
    • is of sufficient seriousness that the applicant’s or member’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 applicant or member must require medical or nursing services that: 
    • are ordered by a physician; 
    • are dependent upon the applicant’s or member'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.

Program Support Unit (PSU) staff must deny or terminate MDCP eligibility when an applicant’s or member’s MN does not meet the level of care (LOC) required for a nursing facility (NF). An applicant’s or member’s approval and continued eligibility for MDCP is dependent upon meeting the MN requirements as listed in 26 TAC Section 554.2401

The tool used to determine MN is the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) completes the SK-SAI and uploads it to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal (LTCOP). The TMHP nurse reviews the SK-SAI to determine if the applicant or member meets the MN criteria required for MDCP once the MCO submits it. The TMHP physician will review the SK-SAI if the TMHP nurse cannot approve the SK-SAI. 

The MCO conducts:

  • initial SK-SAIs for each applicant;
  • reassessment SK-SAIs annually for each member; and
  • a change in condition (CIC) SK-SAIs for each member, when applicable. 

The MCO must notify PSU staff of an applicant’s or member’s MN denial by uploading either Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), or Form H2067-MC, Managed Care Programs Communication (PDF), to TxMedCentral, as appropriate.

PSU staff must monitor the TMHP LTCOP every five business days until the MN status updates to one of the final statuses below:

  • MN Approved: The status may change to "MN Approved" if the TMHP doctor overturns the denial because additional information is received; or 
  • Overturn Doctor Review Expired: The status may change to "Overturn Doctor Review Expired" when the 14-business day period for the TMHP physician to overturn the denied MN has expired, and no additional information or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the applicant, member or legally authorized representative (LAR) requests a fair hearing.

On the 15th business day from the date the “MN Denied” status initially appears in TMHP LTCOP, the MN status will update to “Overturn Doctor Review Expired” when no additional information has been provided to reverse the initial MN denial finding. 

PSU staff must complete the following activities for applicants within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP:

  • electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF), in the TMHP LTCOP following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language; 
  • mail Form H2065-D and Appendix XXVII, MDCP Medical Necessity Denial Attachment, to the applicant or legally authorized representative (LAR);
  • for Medicaid Assistance Only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet (PDF), following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) record in the TMHP LTCOP following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP:

  • electronically generate Form H2065-D in the TMHP LTCOP following the instructions in Appendix II; 
  • mail Form H2065-D and Attachment B, Fair Hearing Options for MDCP Denials, to the member or LAR;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D; 
  • email Enrollment Resolution Services (ERS) Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • terminate the ISP record in the TMHP LTCOP following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing prior to the termination effective date.

The adverse action notification period applies to MN denials. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.6 Unable to Locate

Revision 22-1; Effective January 31, 2022
 
Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when notified an applicant or member cannot be located. PSU staff must process a case closure upon notification that an individual cannot be located.

PSU staff may receive notification that an individual, applicant or member cannot be located by:

  • monthly reports;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the managed care organization (MCO); or
  • other reliable sources.

The MCO must conduct the required contact attempts established in the STAR Kids Handbook (SKH) before requesting a denial or termination from PSU staff. PSU staff are not required to verify the MCO’s contact attempts.

PSU staff must complete the following activities for individuals within two business days of notification:

  • manually generate Form 2442, Notification of Interest List Release Closure (PDF);
  • mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or legally authorized representative (LAR);
  • upload Form H2067-MC, Managed Care Programs Communication (PDF), and Form 2442 to TxMedCentral notifying the MCO of case closure, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet (PDF), following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the CSIL record, if applicable;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document the HEART case record. 

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D; and
  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

The adverse action notification period applies in this situation. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

PSU staff must reinstate MDCP using the historical ISP if the member is located within the historical ISP date range. The ISP begin date must be the first day of the month that the member is located. The ISP end date must be the historical ISP end date.

Note: PSU staff must refer to the Health and Human Services (HHSC) Uniform Managed Care Manual (UMCM)(PDF) for information on processing STAR Health members.

PSU staff must refer to Section 2120, Inability to Contact the Individual, for procedures when unable to contact individuals who have been released from the interest list.

6300.7 Exceeding the ISP Cost Limit

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant’s or member’s individual service plan (ISP) exceeds the cost limit. The intent of MDCP is to serve applicants and members who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems when determining if the ISP meets the needs of the applicant or member. As part of the individual service planning process, the MCO must establish an ISP that does not exceed the applicant’s or member’s cost limit.

The MCO must notify PSU staff when an applicant’s or member’s ISP exceeds the cost limit by uploading Form H2067-MC, Managed Care Programs Communication (PDF), to TxMedCentral. 

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet (PDF), following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable; 
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for members within two business days of notification:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the termination effective date in the TMHP LTCOP, following the instructions in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document the HEART case record.

PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP. 

PSU staff must complete the following activities within two business days of the adverse action notification period’s expiration date if an MAO member has not requested a fair hearing or a fair hearing with continued benefits:

  • complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • email ERS Unit staff the following information:
    • an email subject line that reads: “MDCP Termination for XXX.XXX [first three letters of the member’s first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for ANN.SMI”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., MDCP eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

PSU staff are not required to wait for the adverse action time frame to expire before terminating the ISP for members with other Medicaid types such as members with Supplemental Security Income (SSI). For these members, PSU staff must: 

  • terminate the ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Refer to Section 7200, State Fair Hearing Procedures for Medically Dependent Children Program, if the member requests a fair hearing before the termination effective date.

The adverse action notification period applies in this situation. Refer to Section 6200, Adverse Action Notification Period, to determine the termination effective date.

6300.8 Failure to Obtain Physician’s Signature

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny Medically Dependent Children Program (MDCP) eligibility when the managed care organization (MCO) is unable to obtain a physician’s signature at an initial assessment. The physician’s signature is required to complete the initial STAR Kids Screening and Assessment Instrument (SK-SAI) only. The physician’s signature is not required for the annual SK-SAI. The MCO must notify PSU staff of any delays in processing the assessment by uploading Form H2067-MC, Managed Care Programs Communication (PDF), to TxMedCentral. 
 
The MCO will notify PSU staff if the MCO is unable to obtain a physician’s signature. The MCO must complete and upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral requesting PSU staff deny the applicant due to the MCO’s inability to obtain a physician’s signature when the MCO’s time frame for obtaining the physician’s signature has expired. 

PSU staff must complete the following activities for applicants within two business days of notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet (PDF), following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D notifying the MEPD specialist of the denial, if applicable; 
  • invalidate the individual service plan (ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable; 
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

The adverse action notification period does not apply in this situation.

6300.9 No Longer Meets the Age Requirement for MDCP

Revision 23-3; Effective May 22, 2023

A Medically Dependent Children Program (MDCP) individual, applicant or member must be under 21 years old to be eligible for MDCP per Title 1 Texas Administrative Code (TAC) Section 353.1155.

Program Support Unit (PSU) staff may receive notification that an individual, applicant or member no longer meets the age requirement for MDCP by:

  • the MDCP PDN Transition Report;
  • the managed care organization (MCO); 
  • the individual, applicant, member or legally authorized representative (LAR); or 
  • other reliable sources.

PSU staff must complete the following activities for an individual within two business days from notification:

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XX, MDCP Program Description, to the individual or LAR;
  • upload Form 2442 to TxMedCentral notifying the MCO of case closure, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for an applicant within two business days from notification:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable;
  • document and close the CSIL record, if applicable;
  • invalidate the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

PSU staff must process a case termination notification for an MDCP member no earlier than 45 days and no later than 30 days before the last day of the month the member turns 21. The member will no longer receive MDCP services beginning the last day of the member’s 21st birth month.

PSU staff must complete the following activities no earlier than 45 days and no later than 30 days before the last day of the month the member turns 21:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D and Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • complete the following tasks in the TMHP LTCOP:
    • adjust the SK-ISP end date and the MDCP Enrollment Form end date to the last day of the member's 21st birth month following the instructions in Appendix I, and Appendix XXVIII, PSU TMHP LTC Online Portal MDCP Enrollment Form User Guide;
    • terminate the SK-ISP and MDCP Enrollment Form using the applicable denial reason indicated in Appendix II;
  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist indicating the member aged out of MDCP and the termination effective date; 
  • email the appropriate Intellectual and Developmental Disability (IDD) waiver staff to advise of the MDCP termination date as the last day of the member’s 21st birth month if the member is transitioning from MDCP to an IDD waiver;
  • upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and 
  • document and close the HEART case record. 

Adverse action is not required when an MDCP member transitions to another waiver.

6300.10 Other Reasons

Revision 23-3 Effective May 22, 2023

Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an individual, applicant or member may need a case closure or to be denied or terminated for other reasons not listed in Section 6300.1 through Section 6300.9.

The PSU supervisor will notify PSU staff if: 

  • the case closure, denial or termination can be processed; and
  • what denial reason to use.

PSU staff must complete the following activities for individuals within two business days from PSU supervisor approval to proceed with case closure:

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XX, MDCP Program Description to the individual or legally authorized representative (LAR);
  • upload Form 2442 to TxMedCentral notifying the MCO of case closure following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities for applicants within two business days from PSU supervisor approval to deny the applicant:

  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail Form H2065-D to the applicant or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • for medical assistance only (MAO) applicants, complete Form H1746-A, MEPD Referral Cover Sheet, following the instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist along with Form H2065-D, if applicable; 
  • document and close the CSIL record, if applicable;
  • invalidate the STAR Kids individual service plan (SK-ISP) record in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), following the instructions in Appendix I, PSU User Guide for the SK-ISP Form, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

Note: PSU staff must refer to one of the following sections for more information about traditional Money Follows the Person (MFP) individual and applicant denials, as appropriate:

  • Section 2412.5, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials.
  • Section 2413.5, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials.

PSU staff must complete the following activities for members within two business days from PSU supervisor approval to terminate the member:

  • manually generate Form H2065-D following the instructions in Appendix II;
  • mail Form H2065-D to the member or LAR;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjust the SK-ISP end date to the termination effective date in the TMHP LTCOP;
  • terminate the SK-ISP record in the TMHP LTCOP, following the instructions listed in Appendix I;
  • for MAO members, complete Form H1746-A following instructions in Appendix XV and fax to the MEPD specialist along with Form H2065-D;
  • for MAO members, notify the Enrollment Resolution Services (ERS) Unit by email. The email to the ERS Unit must include the following information:
    • an email subject line that reads: “MDCP Termination for XX [first letter of the member's first and last name].” For example, the email subject line for an MDCP termination for Ann Smith would be “MDCP Termination for AS;”
    • the member’s name;
    • Medicaid (identification) ID number;
    • the type of request (e.g., MDCP eligibility termination);
    • SK-ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document the HEART case record.

The applicability of the adverse action notification period is scenario specific.

PSU staff must refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, if an MAO Medicaid member requests a state fair hearing with continued benefits within the adverse action notification period.

PSU staff is not required to notify the PSU supervisor for the following denial or termination reasons:

  • does not have an unmet need;
  • moved out of state; or
  • declined assessment.

6400, Disenrollment Request Policy

Revision 22-1 Effective January 31, 2022

A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of non-compliance listed in Texas Health and Human Services (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5. These reasons for noncompliance include:

  • misusing or loaning the member’s MCO membership card to another person to obtain services;
  • disruptive, unruly, threatening or uncooperative behavior unrelated to a physical or behavioral health condition to the extent that the member’s membership seriously impairs the MCO’s ability to provide services to the member or to obtain new members; or 
  • steadfast refusal to comply with managed care restrictions (e.g., repeatedly using emergency room in combination with refusing to allow the MCO to treat the underlying medical condition).

A member may also request to be disenrolled from managed care. Disenrollment from managed care means the member wants to remove themselves from managed care and receive services via fee-for-service (FFS) only. The member must receive approval from HHSC to disenroll from managed care. 

Disenrollment is not the same as voluntarily withdrawing from the program. A member may voluntarily withdraw from MDCP without HHSC approval. Examples of scenarios where a member may request to voluntarily withdraw from MDCP include:

  • The member’s name came to the top of another Medicaid waiver program’s interest list, and the member chose to pursue the other Medicaid waiver program and withdraw from MDCP; or
  • The member states they no longer want MDCP because they do not use any MDCP services.

Refer to the HHSC UMCM Chapter 16.2, STAR Health Medically Dependent Children Program (MDCP), for specific requirements for STAR Health members.

Members who receive HHSC approval to disenroll from managed care and maintain Medicaid eligibility, such as Supplemental Security Income (SSI) or SSI-related Medicaid, may continue receiving non-waiver services available through FFS Medicaid. Medical assistance only (MAO) members will lose Medicaid eligibility as well as waiver services. 

Program Support Unit (PSU) staff must refer a member who requests disenrollment from managed care to HHSC Ombudsman’s Managed Care Assistance Team at 866-566-8989 to request to disenroll. 

PSU staff must refer MCOs requesting a member be disenrolled from managed care to follow the policy outlined in UMCM Chapters 11.5 and 11.6

PSU staff must not process disenrollment requests until notified to do so by their supervisor. The Managed Care Compliance & Operations (MCCO) Unit staff and the HHSC Disenrollment Committee will review each member and MCO request to disenroll. MCCO Unit staff will notify Program Enrollment & Support (PES) state office staff of an approved disenrollment request. PES state office staff will notify the appropriate PSU supervisor and request disenrollment. The notification will include the Medicaid Managed Care Member Disenrollment Form and the disenrollment date. 

The PSU supervisor will email the disenrollment request to the assigned PSU staff for processing. PSU staff must complete the following activities within two business days of PSU supervisor assignment:

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record selecting “Disenrollment” in the Action Type field;
  • select “Disenrollment. HPM Request. Add Never Not” as the Issue Type in the HEART case record;
  • terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the effective date provided by the MCCO Unit and the termination reason, “Member requests service termination”; 
  • for MAO members, complete Form H1746-A, MEPD Referral Cover Sheet, following instructions in Appendix XV, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, and fax to the Medicaid the Elderly and People with Disabilities (MEPD) specialist requesting Medicaid termination effective the date of disenrollment provided by the MCCO Unit;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions;
  • document that the member disenrolled in the HEART case record; and
  • close the HEART case record. 

PSU staff must not generate Form H2065-D, Notification of Managed Care Program Services (PDF), for an approved disenrollment. PSU staff are not required to notify Enrollment Resolution Services (ERS) Unit staff or the member of the approved disenrollment. MCCO Unit staff will send a Notice of Ineligibility to the member and work with ERS Unit staff to disenroll the member from managed care.

6500, ISPs Invalidated or Terminated in Error

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must notify the PSU supervisor by email if an individual service plan (ISP) record is invalidated or terminated in error in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The email must include the following:

  • an email subject line that reads: “TMHP ISP Restart Requested for XXX.XXX [first three letters of the applicant or member’s first and last name].” For example, the email subject line for a restart request for Ann Smith would be “TMHP ISP Restart Request for ANN.SMI”;
  • applicant’s or member’s name; 
  • Medicaid identification (ID) number or Social Security Number (SSN); 
  • the ISP record’s document locator number (DLN) number; and 
  • an explanation of the error and reason for restart request. The explanation of the restart request must include the correct termination date if the ISP record was terminated on an incorrect date. 

Refer to Appendix I, PSU User Guide for the SK-ISP Form, for additional direction on moving an ISP record into an invalidated or terminated status in the TMHP LTCOP.

7100, Appeals and State Fair Hearings

Revision 23-4; Effective Aug. 21, 2023

1 Texas Administrative Code (TAC) Section 357.1, Definitions,  states an appeal is a request for a review of an agency action or failure to act that may result in a fair hearing. A Medically Dependent Children Program (MDCP) applicant, member, legally authorized representative (LAR) or medical consenter has the right to request an appeal within 90 days from the effective date of a Texas Health and Human Services Commission (HHSC) action as indicated in 1 TAC Section 357.3,  Authority and Right to Appeal. The appeal request may be verbal or in writing.

A fair hearing is an informal proceeding held before an impartial HHSC hearings officer where an applicant, member, LAR or medical consenter appeals an agency action, as indicated in 1 TAC Section 357 .1. 
 

7200, State Fair Hearing Procedures for Medically Dependent Children Program

7201 Timely or Non-timely State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

An applicant, member, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) may request a state fair hearing orally or in writing.

A timely state fair hearing request for a Medically Dependent Children Program (MDCP) eligibility denial is received by Program Support Unit (PSU) staff no later than 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for an MDCP eligibility denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

If a non-timely state fair hearing request is received from the applicant or member, PSU staff create the appeal in the Texas Integrated Eligibility Redesign System (TIERS). If the hearing officer determines there is good cause, the hearing officer will schedule a state fair hearing date. If the hearing officer determines if there is no good cause, the applicant or member is no longer eligible for a state fair hearing.

7210 Entering a State Fair Hearing In TIERS

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive a verbal or written appeal request related to a Medically Dependent Children Program (MDCP) eligibility denial or termination from an: 

  • applicant;
  • member; 
  • legally authorized representative (LAR); or
  • medical consenter. 

PSU staff must complete the following activities within two business days from the receipt of all appeal requests, except appeal requests resulting from a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denial:

  • create a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • create a fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) following the instructions in Appendix XXI, Creating an Appeal in TIERS.

Note: PSU staff entries in TIERS depend on the issue being appealed. 

TIERS will assign an appeal identification (ID) number when PSU staff complete and submit the fair hearing in TIERS. PSU staff must document the appeal ID number in the HEART case record.

Refer to Section 7213, State Fair Hearing Evidence Packet, for more information on activities PSU staff must complete on the same date as creating the fair hearing in TIERS.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to an MEPD or TW financial eligibility denial. 

7211 Reserved for Future Use

Revision 23-4; Effective Aug. 21, 2023

7212 Generation of the State Fair Hearing Packet

Revision 18-0; Effective September 4, 2018

The Texas Integrated Eligibility Redesign System (TIERS) generates a partial state fair hearing packet, which is available to state fair hearing participants other than the applicant, member or legally authorized representative (LAR), such as Texas Health and Human Services Commission (HHSC), Texas Medicaid & Healthcare Partnership (TMHP), and managed care organization (MCO) staff. A partial state fair hearing packet includes:

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in TIERS that a state fair hearing has been scheduled. The alert in TIERS identifies the hearings officer assigned to the state fair hearing and the date and time of the state fair hearing. PSU staff use this information to monitor for the decision of the state fair hearing. PSU staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) financial denial.

Once a state fair hearing has been scheduled, TIERS generates a full state fair hearing packet, which the hearings officer mails to the applicant, member or LAR. A full state fair hearing packet includes:

7213 State Fair Hearing Evidence Packet

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities on the same day PSU staff enter the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS): 

  • prepare the state fair hearing evidence packet;
  • mail the state fair hearing evidence packet to the applicant, member or legally authorized representative (LAR); 
  • upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal following the instructions in Section 7231, Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal;
  • 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; and
  • document the HEART case record.

PSU staff must not enter state fair hearing requests for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) Medicaid financial denials. Centralized Representative Unit (CRU) is responsible for creating all fair hearings related to MEPD and TW financial denials.

PSU staff must:

  • Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for MEPD or TW financial denials. 
  • Ensure documentation clearly states the state fair hearing is for the Medically Dependent Children Program (MDCP). 

The PSU state fair hearing evidence packet includes the following:

  • Form 4801, State Fair Hearing Evidence Packet Cover Page;
  • Form H2065-D,  Notification of Managed Care Services;
  • the appropriate handbook section, as notated on Form H2065-D; 
  • Appendix XVII, MDCP Eligibility TAC;
  • Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP, as applicable, for members transitioning from MDCP due to turning 21;
  • the following documents, as applicable, for medical necessity (MN) denials or terminations:
    • Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants; or
    • Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – Members; and
    • any written requests for a state fair hearing, first position or advanced placement.

PSU staff must ensure all state fair hearing evidence packets are complete, organized and all pages are numbered to support the agency’s action on appeal.

Other agencies that may be involved in a state fair hearing, such as the managed care organization (MCO), CRU or the Texas Medicaid & Healthcare Partnership (TMHP) will: 

  • generate their own state fair hearing evidence packet;
  • upload their state fair hearing evidence packet to the HHSC Benefits Portal; and
  • mail their state fair hearing evidence packet to the applicant, member or LAR.

The hearings officer mails Form 4803, Notice of Fair Hearing, to the applicant, member or LAR when the state fair hearings is initially requested. The applicant, member, or LAR may fax or mail evidence to the hearings officer if desired. The applicant, member or LAR obtains the hearings officer’s contact information from Form H4803. The hearings officer shares any evidence submitted by the applicant, member or LAR with HHSC.

7214 Changes to the State Fair Hearing Request Summary

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may learn of changes to an applicant or member’s information after entering the fair hearing into Texas Integrated Eligibility Redesign System (TIERS).

PSU staff must complete the following activities as soon as possible but no later than 10 days from notification of the change:

  • verify that a hearings officer has been assigned to the case by checking TIERS;
  • complete Form H4800-A,  Fair Hearing Request Summary (Addendum), with the updated information;
  • upload Form H4800-A to the Texas Health and Human Services Commission (HHSC) Benefits Portal;
  • notify the hearings officer by email. The email to the hearings officer must include the following:
    • an email subject line that reads: Form H4800-A for XX [first letter of the applicant’s or member’s first and last name]
    • applicant or member’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number, as applicable;
    • HHSC State Benefits appeal ID number; 
    • the type of request (i.e., notification of a change); and
    • Form H4800-A;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document the HEART case record.

PSU staff must include the following on Form H4800-A:

  • a clear statement indicating that this is a state fair hearing for Medically Dependent Children Program (MDCP); and
  • the appeal ID number assigned by TIERS in the designated field on Form H4800-A.

PSU staff may also email Form H4800-A to the hearings officer if they encounter issues with uploading Form H4800-A to the HHSC Benefits Portal.

Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for appeal requests related to Medicaid for Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denials. 

Delays in uploading documentation may delay the fair hearing or require the fair hearing to be rescheduled.

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

 

7221 Type of Denials

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff procedures for processing a fair hearing vary based on the denial reason. For example, PSU staff notify the Centralized Representative Unit (CRU) using the Texas Health and Human Services Commission (HHSC) Benefits Portal if the appeal request is a result of a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial eligibility denial. PSU staff create a fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) for all other denial reasons when the applicant or member requests a fair hearing. 

Refer to the following sections for more information about processing an appeal request for the following denial reasons:

  • Section 7221.1,  Medical Necessity Denial by Texas Medicaid & Healthcare Partnership, for a medical necessity (MN) denial reason;
  • Section 7221.2,  Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for a MEPD or TW financial eligibility denial reason;
  • Section 7221.3,  Supplemental Security Income Denial by the Social Security Administration, for a supplemental security income (SSI) denial reason; or
  • Section 7221.4,  Other Denial Reasons, for any other denial reason.
     

7221.1 Medical Necessity Denial by Texas Medicaid & Healthcare Partnership

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities for an appeal request for a medical necessity (MN) denial:

  • create the following within two business days from the receipt of the appeal request: 
    • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
      • Note: The HEART case record must remain open until the fair hearing decision is rendered; 
    • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS) following the instructions in Appendix XXI,  Creating an Appeal in TIERS;
  • prepare, mail and upload the state fair hearing evidence packet on the same date PSU staff create the fair hearing in TIERS;
  • complete Form H4800-A, Fair Hearing Request Summary (Addendum) if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
  • maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
  • monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision; 
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff do not attend the fair hearing for MN denials or terminations.

Refer to Section 7222.1,  Continuation of Medically Dependent Children Program During a State Fair Hearing, for more information about continuing MDCP benefits during the fair hearing. 
 

7221.2 Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 18-0; Effective September 4, 2018

If the state fair hearing decision is related to a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial for a medical assistance only (MAO) applicant or member, Program Support Unit (PSU) staff must forward the request to the Centralized Representation Unit (CRU). The CRU is required to attend the state fair hearing to represent Medically Dependent Children Program (MDCP) financial denials.

Within one business day of receipt of the request, PSU staff must create the following:

  • an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits Portal in the Appeals/RFR tab for the CRU relating to a financial denial for an MAO applicant or member. Refer to Appendix XII, Create an Appeal Task in the HHSC Benefits Portal;
  • an email to CRU at the HHSC Access and Eligibility Services (AES) Fair Hearing mailbox that includes:
    • a subject line that reads: MDCP Appeal Request - client’s initials-XX and last 4-digit case number-XXXX;
    • applicant or member name;
    • Medicaid identification (ID) number (if applicable);
    • type of service (MDCP);
    • specific information requesting the MEPD or TW financial case remain open during the state fair hearing, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. For example, the financial case may need to remain open pending a state fair hearing decision regarding MN. PSU staff must notify the CRU to keep the MEPD or TW case open pending the state fair hearing decision;
    • a copy of Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available); and
    • “Observer” contact information (PSU staff and PSU supervisor);
  • a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) documenting:
    • the receipt date of the state fair hearing request; and
    • notification to the CRU for completion of Form H4800, Fair Hearing Request Summary.

Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

Once the CRU receives a state fair hearing request, the CRU sends an email reply to PSU staff and the PSU supervisor listed as "Observers" within five days, notifying of the completion of Form H4800 and the appeal identification number (ID). Once PSU staff receives the notification, PSU staff upload the notification in HEART and monitor the appeal until the state fair hearing decision is rendered. PSU staff must not put an applicant or member name back on the MDCP program interest list while an MEPD or TW financial denial are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the MEPD or TW financial denial state fair hearing decision is rendered. The applicant or member may choose to be added back to the MDCP interest list if the denial is sustained.

When a state fair hearing decision is rendered by the hearings officer, PSU staff and the PSU supervisor entered as "Observer" are notified by an alert in TIERS of the decision by the hearings officer.

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following the decision of a state fair hearing.

7221.3 Supplemental Security Income Denial by the Social Security Administration

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities for an appeal request for a supplemental security income (SSI) financial eligibility denial:

  • create the following within two business days from the receipt of the appeal request: 
    • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered; and 
    • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS);
  • prepare, mail and upload the state fair hearing evidence on the same day PSU staff create the fair hearing in TIERS;
  • complete Form H4800-A, Fair Hearing Request Summary (Addendum), if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
  • maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
  • attend and present the state fair hearing evidence packet during the fair hearing;
  • monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision; 
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff attend the fair hearing for SSI denials and terminations. Refer to Section 7232, Presentation of the State Fair Hearing Evidence Packet, for more information about PSU procedures during the fair hearing.

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for SSI terminations. 

7221.4 Other Denial Reasons

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive a fair hearing request for other denial and termination reasons. Other denial reasons include:

  • living arrangement is not an allowable setting;
  • voluntarily declined services;
  • unable to locate the applicant or member;
  • failure to obtain physician signature; or
  • exceeding the STAR Kids individual service plan (SK-ISP) cost limit.

PSU staff must complete the following activities for an appeal request not related to a denial reason listed in Sections 7221.1, Medical Necessity Denial by Texas Medicaid & Healthcare Partnership, through Section 7221.3, Supplemental Security Income Denial by the Social Security Administration:

  • create the following within two business days from the receipt of the appeal request: 
    • a new fair hearing Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. Note: The HEART case record must remain open until the fair hearing decision is rendered; and
    • a fair hearing in Texas Integrated Eligibility Redesign System (TIERS);
  • prepare, mail and upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal on the same day PSU staff create the fair hearing in TIERS;
  • complete Form H4800-A, Fair Hearing Request Summary (Addendum), if PSU staff learn of changes to the applicant or member’s information after entering the fair hearing in TIERS;
  • maintain the applicant or member on the Community Services Interest List (CSIL) during the fair hearing, if the CSIL record is open when the applicant or member requested the fair hearing;
  • monitor the fair hearing case for the receipt of the TIERS alert indicating the hearings officer rendered their decision; 
  • upload all applicable documents to the HEART case record; and
  • document and close the HEART case record.

PSU staff do not attend the fair hearing for any other denial reason appeal request except for supplemental security income (SSI) denial reason appeal requests.

Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information about continuing Medically Dependent Children (MDCP) benefits during the fair hearing.

7222 Continuation or Termination of Services

Revision 18-0; Effective September 4, 2018

 

7222.1 Continuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 23-4; Effective Aug. 21, 2023

Medically Dependent Children Program (MDCP) benefits must continue until the hearings officer issues a decision if the member, legally authorized representative (LAR) or medical consenter files an appeal requesting continued benefits:

  • within the adverse action notification period of the MDCP termination; or
  • by the effective date of the action pending the fair hearing.

The deadline is whichever date is later.

Continuation of MDCP benefits during a state fair hearing do not apply for supplemental security income (SSI) terminations. 

Refer to Section 6200, Adverse Action Notification Period, for more information about the adverse action notification period.

PSU staff must complete the following activities on the same date PSU staff create a fair hearing in Texas Integrated Eligibility Redesign System (TIERS) or enter an appeal request in the Texas Health and Human Services (HHSC) Benefits Portal for a medical assistance only (MAO) member when it is determined the member may receive continued benefits, as applicable:

  • extend the existing STAR Kids individual service plan (SK-ISP) in four calendar month intervals until the fair hearing decision is rendered if the hearings officer’s decision will not be made until after the SK-ISP expiration date. Example: The member’s four-month period would end on April 30, 2023, if the SK-ISP expiration date is Dec. 31, 2022, and the state fair hearing decision date will not be made until after Dec. 31, 2022.
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; 
  • document the HEART case record; and
  • monitor the case for the receipt of the TIERS alert indicating the hearings officer’s decision.

HHSC continues services pending the fair hearing decision if the fair hearing is initially dismissed and then subsequently reopened and the member, LAR or medical consenter requests continued benefits. The hearings officer will void the prior fair hearing decision if the hearings officer sets a date for a new fair hearing. The member must continue to receive services until the hearings officer renders a new fair hearing decision. 

PSU staff do not mail Form H2065-D, Notification of Managed Care Program Services, to the member, LAR or medical consenter notifying of continued MDCP benefits.

PSU staff must notify the following parties within three business days from the date the member requests a fair hearing with continued benefits within the adverse action notification period or the effective date of action (whichever is later): 

  • the managed care organization (MCO) by uploading Form H2067-MC,  Managed Care Programs Communication, to TxMedCentral, notating that the MCO must continue to provide services until the hearings officer renders a decision; and
  • for MAO members, email Centralized Representation Unit (CRU) Unit staff at the Texas Health and HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information: 
    • an email subject line that reads: “MDCP Request for Continued Benefits – XX [member’s first and last initials] #### [last four digits of the case number]”;
    • member name;
    • Medicaid identification (ID) number;
    • HHSC Benefits Portal appeal ID number, if available;
    • TIERS case number;
    • type of service (MDCP);
    • reason for termination (e.g., medical necessity denial); and
    • specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD), or Texas Works (TW) financial termination case remain open during the state fair hearing. For example, “The MEPD or TW financial denial case may need to remain open pending a state fair hearing decision about medical necessity (MN)”.

PSU staff must: 

  • upload all applicable documents to the HEART case record; 
  • document the HEART case record; and
  • monitor the case for the receipt of the TIERS alert indicating the hearings officer’s decision. 

7222.2 Discontinuation of Medically Dependent Children Program Services During a State Fair Hearing

Revision 23-3; Effective May 22, 2023

A member’s Medically Dependent Children Program (MDCP) services continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services. The MDCP denial date is the last day of the month of the current STAR Kids individual service plan (SK-ISP) or the last day of the month in which the adverse action notification period ends, whichever is later. Program Support Unit (PSU) staff refer to Section 6200, Adverse Action Notification Period, for more information.

A member who does not request a state fair hearing with continued benefits before the effective date of the denial will not receive continued MDCP services during the state fair hearing. 

7230 State Fair Hearing Actions

Revision 18-0; Effective September 4, 2018

 

7231 Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal on the same day PSU staff enter the state fair hearing.

PSU staff must:

  • select the Appeals/RFR tab and ensure the appeal was entered in the Texas Integrated Eligibility Redesign System (TIERS);
  • select Hearing Evidence Packets Upload and enter the appeal identification (ID) number;
  • select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
  • select Validate;
  • check the details to ensure the right person has been selected;
  • browse for the document (e.g., Form H2065-D, Notification of Managed Care Program Services);  
  • select Upload;
  • 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; and
  • document the HEART case record.

PSU staff must refer to Section 7213, State Fair Hearing Packet, for documentation PSU staff must submit as evidence.

PSU staff must correct errors found in the state fair hearing task in TIERS.

PSU staff must correct errors made on: 

  • the "Agency Representative" screen in TIERS using the "Maintain Appeals" screen in TIERS; and
  • any other screen in TIERS by completing and uploading Form H4800-A, Fair Hearing Request Summary (Addendum), to the HHSC Benefits Portal. 

The "Agency Action Date" cannot be changed.

PSU staff must refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works, for PSU staff responsibilities for Medicaid for Elderly and Persons with Disabilities (MEPD) or Texas Works (TW) financial denials.

7232 Presentation of the State Fair Hearing Evidence Packet

Revision 22-1; Effective January 31, 2022

The hearings officer will not consider documentation in the evidence packet in the state fair hearing decision unless the packet is offered and admitted into evidence. The “Agency Representative” listed on Form H4800, Fair Hearing Request Summary, must present the packet, ask that the documents be admitted as evidence and summarize what the packet contains. Program Support Unit (PSU) staff do not attend state fair hearings unless the hearing is related to a Supplemental Security Income (SSI) denial. Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration, for PSU staff state fair hearing responsibilities. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case.

MCO Example: "I want to offer the following packet as evidence in the state fair hearing filed on behalf of Ned Flanders.

  • Pages 1-10 contain information relating to the completion of Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.
  • Pages 11-15 contain policy from the STAR Kids Handbook (SKH) that relates directly to the issue in question.
  • Pages 16-20 contain documents signed by the applicant, member or legally authorized representative (LAR) related to individual rights.
  • Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or LAR on March 2."

PSU Example: "I want to offer the following packet as evidence in the state fair hearing filed on behalf of Ned Flanders.

  • Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
  • Page 2 contains a copy of Appendix XVII, MDCP Eligibility TAC that states the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies and their contractors and providers in the delivery of STAR Kids Medically Dependent Children Program (MDCP) services to eligible applicants or members. 
  • Page 3 contains a copy of the Section 6300.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR Kids MDCP services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) program requirements.
  • Page 4 contains Form H2065-D, which was mailed to the applicant, member or LAR on March 2nd."

The hearings officer then asks for objections and admits the documents into evidence. The hearings officer explains the reasons for excluding the material if the hearings officer is not able to admit any documents. The hearings officer considers any documents admitted when rendering a decision.

7233 State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff and the PSU supervisor receive an alert in the Texas Integrated Eligibility Redesign System (TIERS) advising that the hearings officer rendered a decision. The hearings officer sends the written decision to the applicant, member, legally authorized representative (LAR) or medical consenter and copies all individuals entered into the fair hearing in TIERS. This includes PSU staff and the PSU supervisor.

The hearings officer renders the following state fair hearing decisions:

  • sustained;
  • sustained with instructions; and
  • reversed.

The hearings officer issues a: 

  • sustained decision when the hearings officer determines the Texas Health and Human Services Commission’s (HHSC’s) action was appropriate per policy and law;
  • sustained with instructions decision when the hearings officer determines HHSC’s action was appropriate per policy and law, but new information was provided and more action is required; or 
  • reversed decision when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) benefits.

The hearings officer will specify the corrective actions to be taken and a 10-day time frame the completion of the actions if the hearing decision is sustained with instructions or reversed.

Refer to Section 7500,  State Fair Hearing Decision Actions, for actions to take when the hearings officer renders their decision.

Refer to Section 7310,  Action Taken on a State Fair Hearing Decision, for additional requirements PSU staff must implement for supplemental security income (SSI) denial fair hearings.
 

7300, Post State Fair Hearing Actions

7310 Action Taken on the State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff complete the following activities for an applicant or member’s fair hearing resulting from a supplemental security income (SSI) denial within 10 days from the date of the fair hearing officer’s decision: 

  • enter PSU staff actions taken because of the hearings officer’s decision in the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS); or
  • complete Form H4807, Action Taken on Hearing Decision, and email it to the hearings officer and the PSU

supervisor notating PSU staff actions taken because of the hearing officer’s decision, if PSU staff is unable to enter the Decision Implementation screen in TIERS.
PSU staff must complete the following activities for an applicant or member’s fair hearing resulting from an SSI denial when PSU staff encounter a delay in implementing the hearings officer’s decision: 

  • notify the PSU supervisor; and
  • enter the reason for the delay in the Decision Implementation screen in TIERS, noting the begin and end delay dates; or
  • complete Form H4807 and email it to hearings officer and the PSU supervisor following Form H4807 instructions if PSU staff are unable to enter the delay in the Decision Implementation screen in TIERS.
     

7500, State Fair Hearing Decision Actions

7510 Sustained State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A sustained fair hearing decision occurs when the hearings officer renders a decision to uphold the Medically Dependent Children Program (MDCP) denial or termination. For example, if an applicant or member fails to appear for a state fair hearing without good cause, the hearings officer will dismiss the appeal (request for the state fair hearing), sustaining the action on appeal. 

7510.1 Sustained State Fair Hearing Decision for Applicants

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain an applicant’s denial:

  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision sustained the action on appeal;
  • close the Community Services Interest List (CSIL) record if the record is open;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, legally authorized representative (LAR) or medical consenter of the sustained termination. 

7510.2 Sustained State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued Medically Dependent Children Program (MDCP) benefits:

  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
    • hearing decision sustained the action on appeal; and
    • MCO must deliver services through the MDCP termination effective date;
  • terminate the STAR Kids individual service plan (SK-ISP) and the Enrollment Form in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7511, Sustained Decision – Termination Date;
  • close the Community Services Interest List (CSIL) record if the record is open;
  • for medical assistance only (MAO) members, email the Centralized Representation Unit (CRU) Unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
    • an email subject line that reads: “Sustained Benefits for MDCP – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”;
    • the member's name;
    • Medicaid identification (ID) number;
    • the type of request (i.e., notification of sustained MDCP benefits); 
    • the type of service (i.e., MDCP);
    • HHSC Benefits Portal appeal ID number;  
      the Texas Integrated Eligibility Redesign System (TIERS) case number;
    • MDCP termination effective date; and
    • the state fair hearing decision.
      • Note: CRU staff will terminate Medicaid eligibility for MAO members.
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member, legally authorized representative (LAR) or medical consenter of the sustained termination.

7510.3 Sustained State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits:

  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision sustained the action on appeal;
  • close the Community Services Interest List (CSIL) record if the record is open;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services, to notify the member, legally authorized representative (LAR) or medical consenter of the sustained termination. 

7511 Sustained Decision – Termination Effective Date

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must adjust the member’s STAR Kids individual service plan (SK-ISP) end date and terminate the SK-ISP per the fair hearings officer’s sustained decision when the member received:

  • continued Medically Dependent Children Program (MDCP) benefits during the fair hearing; and
  • a sustained fair hearing outcome.

The final termination effective date varies depending on the following: 

  • hearings officer’s decision date;
  • original SK-ISP date; and
  • SK-ISP expiration date as a result of the member receiving continued MDCP benefits during the fair hearing.

See below table for further clarification of each scenario.

Scenario 1: PSU staff must adjust the extended SK-ISP end date back to the historical SK-ISP end date if the:

  • member received continued MDCP benefits during the fair hearing;
  • hearings officer’s decision sustains the termination; and
  • hearings officer’s decision is 30 days or more before the end of the historical SK-ISP end date. 

Scenario 2: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date (the date the order is signed) if the:

  • member received continued MDCP benefits during the fair hearing;
  • hearings officer’s decision sustains the termination; and
  • hearings officer’s decision date is 30 days or less before the end of the historical SK-ISP end date.

Scenario 3: PSU staff must adjust the extended SK-ISP end date to the last day of the month that is 30 days from the hearings officer’s decision date if the:

  • member received continued MDCP benefits during the fair hearing;
  • hearings officer’s decision sustains the termination; and
  • hearings officer’s decision date is: 
    • after the end of the SK-ISP in effect when the member filed the state fair hearing; and
      • before the end of the extended SK-ISP date.
ScenariosOriginal SK-ISP End DateNew Extended SK-ISP End DateHearings Officer Decision DateFinal SK-ISP End Date
1. Hearings officer decision date is 30 days or more from the original SK-ISP end date5/31/239/30/234/3/235/31/23
2. Hearings officer decision date is less than 30 days from the original SK-ISP end date5/31/239/30/235/15/236/30/23

3. Hearings officer decision date is:

  • greater than the historical SK-ISP expiration date; and
  • less than the extended SK-ISP end date. 
     
5/31/239/30/236/30/237/31/23

7520 Reversed State Fair Hearing Decision

Revision 23-4; Effective Aug. 21, 2023

A reversed fair hearing decision occurs when the hearings officer determines the Texas Health and Human Services Commission (HHSC) action was not appropriate per policy and law. HHSC is ordered to approve or reinstate Medically Dependent Children Program (MDCP) benefits when the hearings officer issues a reversed fair hearing decision.

7520.1 Reversed State Fair Hearing Decision for Applicants 

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse an applicant’s denial: 

  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the hearing decision reversed the action on appeal;
  • reactivate the STAR Kids individual service plan (SK-ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and the Enrollment Form;
  • edit the SK-ISP and Enrollment Form dates in the TMHP LTCOP using the effective dates noted in Section 7521,  Reversed Decision – Effective Date; 
  • close the Community Services Interest List (CSIL) record if the record is open; and
  • follow current policy noted in the STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) Section 2000, Medically Dependent Children Program Intake and Initial Application,  for approving Medically Dependent Children Program (MDCP) applicants.

7520.2 Reversed State Fair Hearing Decision for Members With Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who received continued Medically Dependent

Children Program (MDCP) benefits: 

  • upload Form H2067-MC, Managed Care Programs Communication , to TxMedCentral notifying the managed care organization (MCO) that the:
    • hearing decision reversed the action on appeal;
    • MDCP benefits must continue as directed in the hearings officer’s decision; and
    • MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • edit the original SK-ISP end date in the TMHP LTCOP to match the historical SK-ISP end date, if applicable;
  • update the MDCP Enrollment Form in the TMHP LTCOP, if applicable;
  • pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of new SK-ISP in the TMHP LTCOP;
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

  • edit the new SK-ISP effective date in the TMHP LTCOP using the effective date noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed; 
  • close the Community Services Interest List (CSIL) record if the record is open;
  • generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
  • upload all applicable documents to HEART case record; and
  • document and close the HEART case record.

7520.3 Reversed State Fair Hearing Decision for Members Without Continued MDCP Benefits

Revision 23-4; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must complete the following activities within two business days from the hearings officer’s decision to reverse the termination of a member who did not receive continued Medically Dependent Children Program (MDCP) benefits: 

  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral notifying the managed care organization (MCO) that the:
  • hearing decision reversed the action on appeal;
  • MDCP benefits must be reinstated as directed in the hearings officer’s decision; and
  • MCO must submit a new STAR Kids individual service plan (SK-ISP) to PSU staff in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • edit the original SK-ISP and Enrollment Form end date in the TMHP LTCOP to match the historical SK-ISP and Enrollment Form end date, if applicable;
  • pend the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record until the receipt of the new SK-ISP in the TMHP LTCOP;
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days from the receipt of the new SK-ISP in the TMHP LTCOP:

  • edit the new SK-ISP and Enrollment Form effective date in the TMHP LTCOP using the effective dates noted in Section 7521, Reversed Decision – Effective Date, and adjust as needed;
  • close the Community Services Interest List (CSIL) record if the record is open;
  •  generate and mail Form H2065-D, Notification of Managed Care Program Services, to the member, legally authorized representative (LAR) or medical consenter;
  • for medical assistance only (MAO) members, email the Enrollment Resolution Services (ERS) Unit staff. The email to the ERS Unit must include the following information:
    • a subject line that reads: “Hearings Officer Decision – STAR Kids MDCP – Reversed Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”; 
    • the member's name;
    • Medicaid identification (ID) number;
    • Health and Human Services Commission (HHSC) Benefits Portal appeal ID number;
    • the Texas Integrated Eligibility Redesign System (TIERS) case number;
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • TIERS Medicaid eligibility effective date;
    • TIERS managed care effective date;
    • the state fair hearing decision; and
    • Form H2065-D; 
  • for MAO members, email the Centralized Representation Unit (CRU) staff at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to the CRU Unit must include the following information:
    • a subject line that reads: “Reinstatement of Benefits for MDCP – Appeal ID ####### for XX [first letter of the member's first and last name]”;
    • the member's name;
    • Medicaid ID number;
    • the type of request (i.e., reinstate Medicaid eligibility); 
    • the type of service (i.e., MDCP);
    • HHSC Benefits Portal appeal ID number;
    • the TIERS number;
    • TIERS Medicaid eligibility effective date;
    • the state fair hearing decision; and
    • Form H1746-A, MEPD Referral Cover Sheet; 
  • upload all applicable documents to HEART case record; and
  • document and close the HEART case record.

7521 Reversed Decision – Effective Date

Revision 23-4; Effective Aug. 21, 2023

The effective begin date for the STAR Kids individual service plan (SK-ISP) for a reversed fair hearing decision depends on if the appellant is an applicant, member with continued Medically Dependent Children Program (MDCP) benefits or member without MDCP continued benefits.

The SK-ISP begin date for an applicant is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer.

The SK-ISP begin date for a member who received continued MDCP benefits is the first day of the month following the end of the SK-ISP in effect when the state fair hearing was filed.

The SK-ISP begin date for a member who did not receive continued MDCP benefits is the first day of the month following the hearings officer’s decision, unless otherwise specified by the hearings officer. 

Program Support Unit (PSU) staff may need to coordinate reinstatement effective dates for medical assistance only (MAO) applicants and members denied Medicaid financial eligibility with the Central Representation Unit (CRU). 
 

7522 New Assessment Required by State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018

If the hearings officer’s decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI) tool, the state fair hearing is closed as a result of this decision. Program Support Unit (PSU) staff must notify the applicant, member or legally authorized representative (LAR) of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. If the new assessment results in a denied medical necessity (MN), the applicant, member or LAR may appeal the results of the new assessment. If the applicant, member or LAR chooses to appeal, PSU staff must indicate in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800, Fair Hearing Request Summary, and also during the state fair hearing that the new assessment was ordered from a previous state fair hearing decision.

If the member or LAR requests a state fair hearing of the new assessment and services are continued, the managed care organization (MCO) continues services until the second state fair hearing decision is rendered. For example, a Medically Dependent Children Program (MDCP) member is denied MN at an annual reassessment and requests a state fair hearing and services are continued. The MCO continues services at the level the member was receiving prior to the MN denial. The hearings officer then orders a new MN assessment, which results in another MN denial. PSU staff send a notice to the member or LAR informing him or her of the MN denial. The member or LAR then request another state fair hearing and services are continued pending the second state fair hearing decision. The MCO continues services at the same level services were provided prior to the first state fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member or LAR requests a state fair hearing due to the lower RUG level, the MCO continues services at the same level services were provided prior to the first state fair hearing. 

7523 Request to Withdraw a State Fair Hearing

Revision 18-0; Effective September 4, 2018

An applicant, member or legally authorized representative (LAR) may withdraw the state fair hearing request orally or in writing by contacting the hearings officer listed on Form H4803, Notice of Hearing. If the applicant, member or LAR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or LAR to contact the hearings officer of the withdrawal by calling the hearings officer’s telephone number listed on Form H4803. If the applicant, member or LAR send a written request to withdraw to PSU staff, PSU staff must forward the written request to the hearings officer listed on Form H4803.

A state fair hearing will not be dismissed based on a PSU staff decision to change the adverse action. All requests to withdraw the state fair hearing must originate from the applicant, member or LAR and must be made to the hearings officer.

If the applicant, member or LAR request to withdraw the state fair hearing more than five business days prior to the state fair hearing date, the hearings officer will process the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and will send a written decision to participants informing them of the state fair hearing cancellation.

If the applicant, member or LAR request to withdraw the state fair hearing within five business days of the state fair hearing date, the hearings officer will notify PSU staff by telephone or email and open the conference line to inform participants of the cancellation.

7600, Roles and Responsibilities of Texas Health and Human Services Commission Hearings Officer

Revision 23-4; Effective Aug. 21, 2023

1 Texas Administrative Code (TAC) Section 357.5 indicates the Texas Health and Human Services Commission (HHSC) hearings officer:

  • conducts the fair hearing as an informal proceeding, not as a formal court hearing, and is not required to follow the Texas Rules of Evidence or the Texas Rules of Civil Procedure;
  • determines whether an applicant, member, legally authorized representative (LAR) or medical consenter requested a fair hearing in a timely manner, or had good cause for failing to do so;
  • schedules a pre-hearing conference to resolve issues of procedure, jurisdiction, or representation, if necessary;
  • requires the attendance of agency representatives, or witnesses, as needed;
  • is prohibited from engaging in ex parte communication, whether verbal or written, with a party or the party's representative or witness relating to matters to be adjudicated; and
  • arranges for reasonable accommodations for disclosed disabilities.

During the fair hearing, the HHSC hearing’s officer:

  • makes the official recording of the hearing;
  • ensures the applicant, member, LAR, medical consenter and HHSC’s rights are protected;
    determines if there is a need for an interpreter;
  • limits the number of people in attendance at the hearing if space is limited;
  • controls the use by others of cameras, videos or other recording devices;
  • administers oaths and affirmations;
  • ensures consideration of all relevant points at issue and facts pertinent to the applicant, member, LAR or medical consenter’s situation at the time the action was taken;
  • considers the applicant, member, LAR or medical consenter’s changed circumstances, when appropriate and possible;
  • requests, receives, and makes part of the record all relevant evidence;
  • regulates the conduct and course of the fair hearing to ensure due process and an orderly hearing;
  • conducts the hearing in a way that makes the applicant, member, LAR or medical consenter feel most at ease; and
  • orders, if determined to be necessary, an independent medical assessment or professional evaluation to be paid for HHSC or HHSC’s designee.

After the hearing, the hearings officer:

  • makes a decision based on the evidence presented at the fair hearing;
  • determines if HHSC’s action is in compliance with statutes, policies, or procedures;
  • allows the applicant, member, LAR or medical consenter to request and receive a copy of the recording at no charge;
  • issues a timely written decision, and includes findings of fact, conclusions of law, pertinent statutes, and a final order; and
  • ensures compliance, orders HHSC to implement the order within the time limits specified in the relevant federal regulation, monitors compliance with the order, and notifies program management if the order is not implemented.
     

8100, Description

Revision 18-0; Effective September 4, 2018

Utilization Review (UR) is a division within the Medicaid and Children’s Health Insurance Program (CHIP) Division of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd Legislature Regular Session, 2013. This bill amended Title 4 Texas Government Code Section 533.00281 to allow HHSC to review utilization of the STAR+PLUS Home and Community Based Services (HCBS) Program. HHSC has extended the scope of UR to include review of appropriate utilization of STAR Kids Medically Dependent Children Program (MDCP) services as well as state plan services provided in STAR Kids.

STAR Kids managed care organizations (MCOs) must allow UR access to documents, assessments, notes and authorizations contained in the MCO STAR Kids member’s file available upon request. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.

Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language

Revision 23-2; Effective May 22, 2023

Program Support Unit (PSU) staff must use Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment not covered in Appendix II.

Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.

PSU staff must enter the denial reason in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) associated with the denial reason on Form H2065-D and Form H2065-DS. The denial reason in the TMHP LTCOP associated with the denial reason on Form H2065-D and Form H2065-DS is listed in the TMHP Denial Reason column in the table below.

Denial and Termination Reason Language

The table below contains language PSU staff must enter in the Reason for Denial and Comments field on Form H2065-D and Form H2065-DS for denials and terminations.

PSU staff must enter the associated STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section supporting the denial reason on Form H2065-D and Form H2065-DS, listed in the SKOPH Section column.

Purpose of Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSKOPH SectionTMHP Denial Reason
Unable to Locate

You are not eligible for MDCP because HHSC staff or your health plan cannot locate you to complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.

PSU staff must not enter comments language.6300.6Applicant/Member whereabouts are unknown
Voluntarily Declined Services

You are not eligible for MDCP because you voluntarily withdrew from the program.

Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa.

PSU staff must not enter comments language.6300.3

Applicant: Applicant requested application for services be closed

Member: Member requests service termination

Enrolled in Another 1915(c) Medicaid Waiver

You are not eligible for MDCP. This is because you are enrolled in another Medicaid waiver program. You can only be enrolled in one Medicaid waiver program at a time.

Usted no reúne los requisitos para el programa MDCP. Esto se debe a que usted está inscrito en otro programa con exenciones de Medicaid. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez.

You are not eligible for MDCP. This is because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); Texas Home Living (TxHmL)]. MDCP cannot be authorized. You can only be enrolled in one Medicaid waiver program at a time.

Usted no reúne los requisitos para el programa MDCP. Esto se debe a que usted está inscrito actualmente en [Select one: Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS); Programa para Personas Sordociegas con Discapacidades Múltiples (DBMD); Programa de Servicios en el Hogar y en la Comunidad (HCS); Programa de Texas para Vivir en Casa (TxHmL)]. No se puede autorizar el programa MDCP. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez.

6110Applicant/Member can only be enrolled in one 1915(c) waiver program at a time
Financial Eligibility

You are not eligible for MDCP because you do not meet the financial criteria necessary for the program.

Usted no puede recibir servicios del MDCP porque no cumple los criterios financieros necesarios para participar en el programa.

Call 2-1-1 if you have questions about the Medicaid application process.

Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid.

6300.4Applicant/Member denied Medicaid eligibility
Declined Assessment

You are not eligible for MDCP because you did not let your health plan complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque no permitió que el plan médico realizara la valoración que requiere el programa.

PSU staff must not enter comments language.6110Applicant/Member failure to provide information
Living Arrangement is Not an Allowable Setting

You are not eligible for MDCP because where you live is not an allowable setting to receive services. Code of Federal Regulations at Title 42 CFR Section 441.301(c)(5) describes these settings.

Usted no puede recibir beneficios de MDCP porque donde vive no es un entorno adecuado para recibir servicios. Estos servicios están descritos en la sección 441.301(c)(5) del título 42 del Código de Reglamentos Federales (CFR).

PSU staff must not enter comments language.6300.2Applicant/Member does not reside in an allowable living arrangement
Does Not Have an Unmet Need

You are not eligible for MDCP because you do not need services offered through the program.

Usted no puede recibir los servicios del MDCP porque no los necesita.

PSU staff must not enter comments language.6110Applicant and Member: Need for at least one waiver service per individual service plan year
Failure to Obtain Physician's Signature

You aren't eligible for MDCP because your doctor didn't tell us you need the level of care provided in a nursing home.

Usted no puede recibir los servicios del MDCP porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.

PSU staff must not enter comments language.6300.8Applicant/Member failure to provide information
Medical Necessity and Level of CareReason for denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTOCP).

You are not eligible for MDCP. See the Reason for Denial text box on page 1 of this form and the MDCP Medical Necessity Denial Attachment for more information.

Usted no puede recibir servicios del MDCP. Para más información, vea el cuadro “Motivo de la denegación”, en la página 3 de este formulario, y el anexo “Medical Necessity Denial” (denegación por no existir una necesidad médica) del MDCP.

6300.5Applicant and Member: Denied Medical necessity/level of care
Exceeding the ISP Cost Limit

You are not eligible for MDCP because the cost of your individual service plan exceeds the maximum amount allowed.

Usted no puede recibir servicios del MDCP porque el costo de su plan individual de servicios excede la cantidad máxima permitida.

PSU staff must not enter comments language.6300.7Applicant and Member: Exceeds cost limit
MFP Services Not Authorized Within 24 Hours

You are not eligible for MDCP because services were not authorized within 24 hours of the nursing facility stay.

Usted no puede recibir servicios del MDCP porque los servicios no se autorizaron en las 24 horas siguientes a su estancia en el centro de reposo.

PSU staff must not enter comments language.2428Applicant: PSU staff must contact their supervisor for the appropriate TMHP denial reason.
MFP NF Discharge Prior to Eligibility Determination

You are not eligible for the MDCP because you left the nursing facility before HHSC could determine program eligibility.

Usted no reúne los requisitos para recibir servicios del MDCP porque abandonó el centro de reposo antes de que la HHSC pudiera determinar si reunía los requisitos del programa.

PSU staff must not enter comments language.2001Applicant: Failure to Follow Service Plan
Institutional Stay Over 90 Days

You are not eligible for MDCP because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR Section 441.301(b)(1).

Usted no puede recibir servicios del MDCP porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR).

You are not eligible for MDCP services while an in-patient of a [Select one: hospital; nursing facility; intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del MDCP mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; un centro de atención intermedia para personas con discapacidad intelectual].

6300.2Applicant and Member: Institutional stay
Moved Out of State

You are not eligible for MDCP because you are not a Texas resident.

Usted no puede recibir servicios del MDCP porque no reside en Texas.

PSU staff must not enter comments language.6110Applicant/ Member: Member moved out of state

Over Age 20 and:

  • Member declines another Medicaid waiver; or 
  • Ages out before eligibility is established for another Medicaid waiver 

You are not eligible for MDCP because you are 21 or older.

Usted no puede recibir servicios del MDCP porque es mayor de 21 años.

PSU staff must not enter comments language.6300.9Applicant/Member must be age 20 years or younger to be eligible for MDCP services
Over Age 20 and Member Transitions to Another Medicaid Waiver

You are not eligible for MDCP because you are 21 or older.

Usted no puede recibir servicios del MDCP porque es mayor de 21 años.

PSU staff must not enter comments language.6300.9Member: Transition to an adult Program
OtherPSU staff must contact supervisor.PSU staff must contact supervisor.PSU staff must contact supervisor.Applicant/Member: PSU staff must contact their supervisor for the appropriate TMHP denial reason.

Approval Language

The table below contains language PSU staff must enter in the Comments field on Form H2065-D and Form H2065-DS for approvals. 

Purpose of Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSKOPH SectionTMHP Denial Reason
Medicaid Eligibility Reinstated within Six MonthsNo reason for denial language should be added.

Your Medicaid was reinstated on [DATE]. Your MDCP services will continue without interruption.

Su participación en el programa Medicaid fue restablecida el [DATE]. Usted seguirá recibiendo servicios del MDCP sin interrupción.

N/AN/A
Initial Form H2065-D for MFP to CommunityN/A

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive a second Form H2065-D telling you when your services will begin.

Ud. cumple los requisitos del MDCP. Sus servicios no empezarán hasta que usted y su plan médico acuerden una fecha para su salida de la casa de reposo. Permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén vigentes cuando salga de la casa de reposo. Usted recibirá un segundo Formulario H2065-D en el que se le informará cuándo comenzarán sus servicios.

N/AN/A
Initial Form H2065-D for MFP to AFCN/A

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive another notice telling you when your MDCP services will begin. We will also send you a notice telling you how much your room and board and copayment will be.

Usted cumple los requisitos del programa MDCP. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa MDCP. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.

N/AN/A
Room and Board and CopaymentN/A

You must pay room and board and any copayment. You will pay them every month to your foster care home or assisted living facility.

Ud. tiene que cubrir los gastos de alojamiento y comida y de cualquier copago. Deberá pagarlos cada mes al hogar de acogida o centro de vida asistida en el que se encuentre.

N/AN/A

Note: PSU staff must enter “Pending” and “Calculando” in the Copayment fields on the English and Spanish versions of Form H2065-D, if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist has not provided copayment amounts at the time Form H2065-D is generated. This applies to cases where an applicant or member has or will have a copayment.

Appendix XVIII, STAR Kids HEART Naming Conventions

Revision 23-3; Effective May 22, 2023

This appendix outlines the screenshots Program Support Unit (PSU) staff must upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix IX, STAR Kids TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.

PSU staff must add a sequence number after the naming convention when more than one of the same form or screenshot is uploaded. For example, PSU staff must name the first Form H1746-A sent or received as 1746_1, the second form sent or received as 1746_2 and the third form sent or received as 1746_3, etc.

PSU staff must upload all screenshots, forms, documents and emails marked as “Yes,” in the “Required” column in the HEART case record. PSU staff must include screenshots, forms, documents and emails marked with an “*” in the “Required” column in the HEART case record if used by PSU staff while completing the case.

Interest List Release (ILR)

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Authorization ScreenshotSASO SAYes
CSIL Closure ScreenshotCSIL CLOSUREYes
Form 2442 (English)2442*
Form 2442-S (Spanish)2442-S*
Form 2442 Screenshot of Upload to TxMedCentralUse TxMedCentral Naming Convention*
Form 26022602*
Form 2604 (if received through TMHP LTCOP)LTCOP ISPYes
Form 2604 (if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826H1826*
Form H2053-B2053B*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065*
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming Convention*
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMED*
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Form H3676-AUse TxMedCentral Naming ConventionYes
Form H3676-A Upload to TxMedCentral3676A TXMEDYes
Form H3676-BUse TxMedCentral Naming ConventionYes
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CCSECCSE EMAIL*
Emails to and from CRUCRU EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from IDD UnitIDD EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*
MEPD Communication ToolMEPD EMAIL*

Note: PSU staff must upload Form 2442 or Form H2065-D in the HEART case record, as appropriate.

Money Follows the Person (MFP)

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual- Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Authorization ScreenshotSASO SAYes
CSIL Closure ScreenshotCSIL CLOSUREYes
Form 2604 (if received through TMHP LTCOP)LTCOP ISPYes
Form 2604 (if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
H1826, Case Information ReleaseH1826*
Form H2053-B2053B*
Form H2065-D Generated in TMHP LTC Online Portal (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CCSECCSE EMAIL*
Emails to and from CRUCRU EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from IDD UnitIDD EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*
MEPD Communication ToolMEPD EMAIL*

Annual Reassessment

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
Form 2604 (if received through TMHP LTCOP)LTCOP ISPYes
Form 2604 (if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form 26062606*
Form 2606-S2606-S*
H1826, Case Information ReleaseH1826*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming Convention*
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMED*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from IDD UnitIDD EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*

Transition to Adult Programs (MDCP Age-Out)

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
H1826, Case Information ReleaseH1826*
Form H2053-B2053B*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming Convention*
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMED*
Form H21162116*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CCSECCSE EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from Higher Needs CoordinatorHN EMAIL*
Emails to and from IDD UnitIDD EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from STAR+PLUS PSUPSU EMAIL*
Emails to and from URUR EMAIL*
MEPD Communication ToolMEPD EMAIL*

Denials and Terminations

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
CSIL Closure ScreenshotCSIL CLOSURE*
Form 2128120 Day NTCE*
Form 26062606*
Form 2606-S2606-S*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
H1826, Case Information ReleaseH1826*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065*
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming Convention*
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMED*
Form H2067-MCUse TxMedCentral Naming Convention*
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMED*
Appendix XXVII, Fair Hearing Options for MDCP Denials – ApplicantsMN DENIAL ATCH*
Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – MembersMN DENIAL ATCH*
Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP ATCH D*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CRUCRU*
Emails to and from ERSERS EMAIL*
Emails to and from IDD UnitIDD EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSU supervisor for 120-day exception requestEXCEPTION REQ EMAIL*
MEPD Communication ToolMEPD EMAIL*

Note: PSU staff uploads Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.

Fair Hearings

ItemHEART Naming ConventionRequired
Form 26062606*
Form 2606-S2606-S*
Form 4801FH COVER LTRYes
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
H1826H1826*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Form H48004800*
Form H4800-A4800A*
Form H48034803Yes
Form H48064806*
Form H48074807*
Copy of Handbook Section Referenced on Form H2065-DSKOPH [####]Yes
Appendix XVII, MDCP Eligibility TACELIGIBILITY TACYes
Appendix XXVII, Fair Hearing Options for MDCP Denials – Applicants MN DENIAL ATCH*
Appendix XXIV, Fair Hearing and Interest List Options for MDCP Denials – MembersMN DENIAL ATCH*
Appendix XXIX, Fair Hearing and Interest List Options for Aging Out of MDCP (English)ATCH D*
Notice of Hearing Officer’s DecisionAPPEAL DECISION LTRYes
HHSC Benefits Portal Screenshot of Hearing Officer's DecisionTIERS APPEAL DECISIONYes
Emails to and from CRUCRU EMAIL*
Emails to and from ERSERS EMAIL*
MEPD Communication ToolMEPD EMAIL*

Disenrollment

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
TMHP LTCOP ISP Termination ScreenshotDISENISP*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Medicaid Managed Care Member Disenrollment FormDISENFORMYes
Emails for PSU QA ProcessQA EMAIL*
Emails to and from MCCOMCCO EMAILYes
MEPD Communication ToolMEPD EMAIL*

Glossary

Revision 22-1; Effective January 31, 2022

A

Abuse — The infliction of injury, unreasonable confinement, intimidations, punishment, mental anguish, sexual abuse or exploitation of a person. Types of abuse include:

  • Physical abuse (a physical act by a person that may cause physical injury to another person).
  • Psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean a person).
  • Sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual exploitation, sexual harassment or inappropriate or unwanted touching of a person by another).
  • Verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or humiliate a person).

Action — An action is defined as the:

  • denial or limited authorization of a requested Medicaid service, including the type or level of service;
  • reduction, suspension, or termination of a previously authorized service;
  • failure to provide services in a timely manner;
  • denial in whole or in part of payment for a service; or
  • failure of an MCO to act within the time frames set forth by the HHSC and state and federal law.

An "action" does not include expiration of a time-limited service.

Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.

Acute Care — Preventive care, primary care, and other medical care provided under the direction of a provider for a condition having a relatively short duration.

Adult — A person 18 years of age or older, or an emancipated minor.

Adverse Action — A termination, suspension or reduction of Medicaid eligibility or covered services.

Agency Option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.

Appeal — A request for a state fair hearing concerning an HHSC action.

Applicant — A person who has been released from the interest list or is pursuing the MFP process for the MDCP or the STAR+PLUS HCBS program, and has either:

  • submitted Form H1200, Application for Assistance – Your Texas Benefits; or
  • had the STAR Kids Screening and Assessment Instrument (SK-SAI) or the Medical Necessity and Level of Care (MN/LOC) assessment conducted by the MCO. 

Authorized Representative (AR) — For medical programs, the person designated with written consent by an individual, applicant, member or recipient to:

  • sign an application on the individual’s, applicant’s or member’s behalf;
  • complete and submit a renewal form;
  • receive copies of the individual’s, applicant’s or member’s notices and other communications from the agency; and
  • act on behalf of the individual, applicant or member in all other matters with the agency.

Behavioral Health Service — A covered service for the treatment of mental, emotional or substance use disorders.

Business Day — Any day except a Saturday, Sunday or legal holiday listed in the Texas Government Code, §662.021.

Capitated Service — A benefit available to members under the Texas Medicaid program for which an MCO is responsible for payment.

Capitation Rate — A fixed predetermined fee paid by HHSC to the MCO each month, in accordance with the contract, for each enrolled member in exchange for which the MCO arranges for, or provides a defined set of covered services to the member, regardless of the amount of covered services used by the enrolled member.

Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.

Centers for Medicare and Medicaid Services (CMS) — The federal agency that administers Medicare and Medicaid.

Client — Any Medicaid-eligible recipient.

Code of Federal Regulations (CFR) — The codified federal regulatory law that governs most federal programs, including Medicaid.

Community Care Services Eligibility (CCSE) —  A group of services purchased by HHSC in response to recommendations of the Texas Legislature. CCSE provides services in a person's own home or community for aged or disabled Texans who are not self-sufficient, and who might otherwise be subject to premature institutionalization or to abuse, neglect or exploitation.

Community First Choice (CFC) Option — PAS habilitation services focused on the acquisition, maintenance and enhancement of skills; emergency response services; and support management provided in a community setting for eligible Medicaid members in the MDCP and STAR+PLUS HCBS program who have received an institutional LOC determination.

Community Living Assistance and Support Services (CLASS) — A non-capitated 1915(c) Medicaid waiver which provides home and community-based services to people with intellectual or developmental disabilities, other than intellectual disability, as an alternative to residing in an intermediate care facility.

Complaint — Any dissatisfaction expressed by a complainant, orally or in writing, to the MCO about any matter related to the MCO other than an action. Subjects for complaints may include:

  • the quality of care of services provided;
  • aspects of interpersonal relationships such as rudeness of a provider or employee; and
  • failure to respect the individual's, applicant's or member's rights.

Comprehensive Care Program (CCP) — A package of Medicaid services available to clients based on medical necessity that goes beyond regular Medicaid services for all ages and is part of the THSteps benefit for clients under age 21.

Consumer Directed Services (CDS) Employer — A member, AR, LAR, parent or court appointed guardian who chooses to participate in the CDS option and therefore is responsible for hiring and retaining service providers to deliver program services.

Consumer Directed Services (CDS) Option — A service delivery option in which a member, AR or LAR employs and retains service providers and directs the delivery of STAR+PLUS HCBS program PAS and respite services. A member participating in the CDS option is required to use an FMSA chosen by the member, AR or LAR to provide financial management services.

Continued Benefits — Continuing or restoring benefits to the level authorized immediately before the notice of adverse action.

Co-payment — The amount of personal income a person must pay toward the cost of his or her care. Co-payment was formerly known as applied income.

Covered services — Unless a service or item is specifically excluded under the terms of the Medicaid state plan, a federal waiver, a managed care services contract, or an amendment to any of these, the phrase "covered services" means all health care, long term services and supports, or dental services or items that the MCO must arrange to provide and pay on a member's behalf under the terms of the contract executed between the MCO and HHSC, including:

  • all services or items comprising "medical assistance," as defined in §32.003 of the Human Resources Code; and
  • all value-added services under such contract.

D

Day — A calendar day, unless otherwise specified in the text. A calendar day includes weekends and legal holidays.

Day Activity and Health Services (DAHS) — Licensed DAHS facilities provide daytime services, up to 10 hours per day, Monday through Friday, to people who live in the community. Services address physical, mental, medical and social needs. People may attend up to five days per week, depending on their eligibility.

Deaf Blind with Multiple Disabilities (DBMD) — A non-capitated 1915(c) Medicaid waiver which provides home and community-based services to people who are deaf and blind and have a third disability.

Denial — Closure of an application with a finding of ineligibility.

Designated Representative (DR) — A willing adult appointed by the CDS employer to assist with, or perform, the employer's required responsibilities to the extent approved by the employer. A DR, usually a family member, is not a paid service provider and is at least age 18.

Disability — A physical or mental impairment that substantially limits one or more of a person's major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, socializing or working.

Dual Eligible — A Medicaid recipient who is also eligible for Medicare.

Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in a person's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — A federal Medicaid benefit for MDCP members under 21 years (called THSteps in Texas).

Eligibility Date — The first date all eligibility criteria are met.

Emergency Response Services (ERS) — Services provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the person can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure that the appropriate person or service provider responds to an alarm call from a person.

Emergency Service — A covered inpatient and outpatient service, furnished by a network provider or out-of-network provider that is qualified to furnish such service, that is needed to evaluate or stabilize an emergency medical condition and/or an emergency behavioral health condition. For health care MCOs, the term "emergency service" includes post-stabilization care services.

Enrollment — The process by which a member determined to be eligible for Medicaid is enrolled in a Medicaid MCO serving the service area in which the member resides.

Enrollment Broker — A contracted entity that assists individuals, applicants and members in selecting and enrolling with an MCO. If requested, the enrollment broker also may assist the member in choosing a PCP.

Exploitation — An act of depriving, defrauding or otherwise obtaining the personal property of a person by taking advantage of a person's disability or impairment.

Fair Hearing — An administrative procedure that affords applicants and members the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by HHSC.

Family Member — A person who is related by blood, affinity or law to an individual, applicant and member.

Federal Waiver — Any waiver permitted under federal law and approved by CMS that allows states to implement Medicaid managed care.

Financial Management Services (FMS) —  Services delivered by the FMSA to the member, LAR, or AR who chooses the CDS option, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member, LAR, or AR.

Financial Management Services Agency (FMSA) — An agency that contracts with the MCO to provide FMS to members who choose the CDS option.

Functional Necessity — A member's need for services and supports with ADLs or IADLs to be healthy and safe in the most integrated setting possible. This determination is based on the results of a functional assessment.

Guardian — A person appointed as a guardian of the estate or of the person by a court.

Habilitation — Acquisition, maintenance, and enhancement of skills necessary for the applicant and member to accomplish ADLs, IADLs, and health-related tasks based on the applicant's and member's person-centered service plan.

Health Information — Any information, whether oral or recorded in any form or medium, that:

  • is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
  • relates to the past, present, or future physical or mental health or condition of any individual, applicant and member; the provision of health care to an individual, applicant and member; or the past, present, or future payment for the provision of health care to an individual, applicant or member.

Health Maintenance Activity (HMA) — A task that may be exempt from delegation based on the registered nurse assessment that enables the member to remain in an independent living environment, and goes beyond activities of daily living because of the higher skill level required to perform.

Health Insurance Portability and Accountability Act (HIPAA) — A federal law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

Home and Community-based Services (HCS) — A non-capitated 1915(c) Medicaid waiver which provides home and community-based services to a person with an intellectual or developmental disabilities as cost-effective alternatives to institutional care.

Income — Any item a person receives in cash or in-kind that can be used to meet his or her need for food or shelter. For purposes of determining MEPD financial eligibility, income includes the receipt of any item that can be applied, either directly or by sale or conversion, to meet the basic needs of food or shelter.

Individual — A person who has been released from the interest list or is pursuing the MFP process for the MDCP or the STAR+PLUS HCBS program, and has not:

  • submitted Form H1200, Application for Assistance - Your Texas Benefits; or
  • had the STAR Kids Screening and Assessment Instrument (SK-SAI) or the Medical Necessity and Level of Care (MN/LOC) assessment conducted by the MCO. 

Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.

Individual Service Plan (ISP) — An individualized and person-centered plan in which a member enrolled in the STAR+PLUS HCBS program operated by the MCO, with assistance as needed, identifies and documents his or her preferences, strengths, and health and wellness needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The ISP is supported by the results of the member's program-specific assessment and must meet the requirements of 42 CFR §441.301.

Individual Service Plan (ISP) Service Tracking Tool — This tool is developed at least annually by the member, MCO and family members to document necessary MDCP services determined by the member’s team and the budget associated with delivering the services. The total cost of the member’s budget provided on this tool must be below the determined cost limit. This is also known as Form 2604.

Institutional Care — Long-term nursing care, treatment or services received in a Medicaid-certified long-term care facility.

Institutional Setting — A living arrangement in which a person applying for or receiving Medicaid lives in a Medicaid-certified long-term care facility or receives services under an HCBS waiver program. Formerly known as a vendor living arrangement.

Instrumental Activities of Daily Living (IADLs) — Activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, doing laundry, and using a telephone.

Intellectual and Developmental Disability (IDD) — A disability with onset during the developmental period that includes limitations in both intellectual and adaptive functioning, which covers many everyday conceptual, social, and practical skills. IDD can begin at any time, up to age 22. It usually lasts throughout a person's lifetime.

Interdisciplinary Team (IDT) — All entities involved in planning the member’s plan of care (POC). This typically includes the member, AR, LAR, service coordinator and primary care physician, etc.

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) — A Medicaid-certified facility that provides care in a 24-hour specialized residential setting for people with an intellectual disability or related conditions. An ICF/IID includes a state supported living center and a state center.

Interest List (IL) — A list of people who have contacted HHSC and expressed an interest in receiving waiver services, but who have not applied for or been determined eligible for services.

Legal Holiday — A legal holiday, including national and state holidays, as defined in the Texas Government Code, §662.003.

Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of a member, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult, as defined by state or federal law, including Texas Occupations Code §151.002(6), Texas Health and Safety Code §166.164, and Texas Estates Code §752.

Level of Care (LOC) — The type of care a person is eligible to receive in an ICF/IID based upon an assessment of the person's need for care.

Local Intellectual and Developmental Disability Authorities (LIDDAs) — Authorities that serve as the point of entry for publicly funded IDD programs, whether the program is provided by a public or private entity. LIDDAs:

  • provide or contract to provide an array of services and supports for persons with IDD;
  • are responsible for enrolling eligible people into the following Medicaid programs:
    • ICF/IID, which includes state supported living centers;
    • HCS;
    • TxHmL; and
  • are responsible for permanency planning for persons under 22 years of age who live in an ICF/IID, state supported living center or a residential setting of the HCS Program.

Long Term Services and Supports (LTSS) — A service provided to a qualified member in his or her home or other community-based setting necessary to allow the member to remain in the most integrated setting possible; and to assist members in living in the community as opposed to an institutionalized setting. LTSS includes services provided under the Medicaid state plan as well as services available to persons who qualify for STAR+PLUS HCBS or 1915(c) Medicaid waiver services. LTSS available through an MCO in STAR+PLUS, STAR Health, and STAR Kids varies by program model.

Managed Care Compliance & Operations (MCCO) — A unit within the Medicaid/Children's Health Insurance Program (CHIP) Division of HHSC that is responsible for administrative and operational aspects of administering the Medicaid managed care programs.

Managed Care Organization (MCO) — An established health maintenance organization or Approved Non-Profit Health Corporation (ANHC) that arranges for the delivery of health care services. In accordance with §843 of the Texas Insurance Code, it is currently licensed as such in the state of Texas.

Medicaid — A program administered by the federal CMS, and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.

Medicaid Eligible — A person who is financially eligible for Medicaid because the person receives SSI cash benefits or is determined by HHSC to be financially eligible for Medicaid.

Medicaid Estate Recovery Program (MERP) — A program that requires HHSC, as the state Medicaid agency, to recover the costs of Medicaid long-term care benefits received by certain Medicaid recipients. For further information, see the MERP website at https://hhs.texas.gov/laws-regulations/legal-information/medicaid-estate-recovery-program/merp-rules-statutes-forms.

Medicaid for the Elderly and People with Disabilities (MEPD) — A public assistance program providing medical assistance, institutional and community-based health-related care, and Medicare cost-sharing assistance for the elderly and people with disabilities. MEPD does not provide cash assistance.

Examples of MEPD services and programs are:

  • primary home care services;
  • HCBS waiver programs, which provide community-based care as an alternative to institutional care;
  • care in a Medicaid-certified long-term care facility;
  • the Program of All-Inclusive Care for the Elderly (PACE);
  • Medicaid Buy-In programs; and
  • Medicare Savings Programs.

Medical Assistance Only (MAO) — A person who qualifies financially and functionally for Medicaid assistance but does not receive SSI benefits, as defined in Title 1 Texas Administrative Code (TAC) §358, §360, and §361 (relating to MEPD, Medicaid Buy-In Program and Medicaid Buy-In for Children Program).

Medical Necessity (MN) — The medical criteria a person must meet for admission to a Texas NF as defined in Title 26 Texas Administrative Code (TAC) §554.2401.

Medically Dependent Children Program (MDCP) — A 1915(c) Medicaid waiver program that provides LTSS HCBS to help the primary caregiver care for an member with an NF level of need and their families in the community.

Medicare — The federal health insurance program for people age 65 or older, certain younger people with disabilities and people with end-stage renal disease (ESRD).

Member — A person who is currently enrolled in, and receiving services through, the MDCP or STAR+PLUS HCBS program.

Money Follows the Person (MFP) — A process whereby the funds used for payment of institutional care follows the person when transitioning; used when an individual or applicant in a Medicaid-certified NF requests to move to the community is Medicaid-eligible and approved for the MDCP or STAR+PLUS HCBS program before leaving the NF.

Mutually Exclusive Services — Two or more services that may not be authorized for the same member during the same time period.

Neglect — The failure to provide a person the reasonable care required, including but not limited to:

  • food;
  • clothing;
  • shelter;
  • medical care;
  • personal hygiene; and
  • protection from harm.

Non-capitated Service — A benefit available to members under the Texas Medicaid program for which an MCO is not responsible for payment.

Non-institutional Setting — A living arrangement in which a person applying for, or receiving, Medicaid does not live in a long-term care facility or receive services under an HCBS waiver program. Formerly known as a non-vendor living arrangement.

Nursing Facility (NF) — A residential institution that primarily provides:

  • skilled nursing care and related services for residents who require medical or nursing care;
  • rehabilitation services for the rehabilitation of injured, disabled or sick people; or
  • health-related care and services, on a regular basis, to people who, because of their mental or physical condition, require care and services, above the level of room and board, which can be made available to them only through institutional facilities.

Person-centered Planning — A documented service planning process that:

  • includes people chosen by the applicant or member;
  • is directed by the applicant or member to the maximum extent possible;
  • enables the applicant or member to make choices and decisions;
  • is timely and occurs at times and locations convenient to the applicant or member;
  • reflects cultural considerations of the applicant or member;
  • includes strategies for solving conflict or disagreement within the process;
  • offers choices to the applicant or member regarding the services and supports they receive and from whom;
  • includes a method for the applicant or member to require updates to the plan; and
  • records alternative settings that were considered by the applicant or member.

Personal Assistance Services (PAS) — A range of services provided by one or more persons designed to assist a person with a disability to perform daily living activities on or off the job that the person would typically perform without assistance if the person did not have a disability.

Personal Care Services (PCS) — Services that include bathing, dressing, preparing meals, feeding, grooming, taking self-administered medication, toileting, ambulation, and assistance with other personal needs or maintenance.

Personal Identifiable Information (PII) — Information that is a subset of health information, including demographic information collected from a person, and:

  • is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
  • relates to the past, present, or future physical or mental health or condition of a person; the provision of health care to a person; or the past, present, or future payment for the provision of health care to a person; and 
    • that identifies the person; or
    • with respect to which there is a reasonable basis to believe the information can be used to identify the person.

Plan of Care (POC) — A care plan the MCO develops for its members that includes acute care and LTSS. The POC is not the same as the ISP.

Primary care provider (PCP) — A physician or other provider who has agreed with the health care MCO to provide a medical home to members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.

Program Support Unit (PSU) Staff — An HHSC unit of staff who support and handle certain aspects of the STAR Kids program and STAR+PLUS program.

Protected Health Information (PHI) — The HIPAA Privacy Rule provides federal protections for PHI held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.

Provider — An appropriately credentialed and licensed person, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.

Qualified Income Trust (QIT) (a.k.a. Miller Trust) — An irrevocable trust specially designed to legally divert a person or married couple’s income into a trust resulting in the income being excluded for purposes of determining eligibility for nursing home (“institutional”) Medicaid and 1915(c) Medicaid waiver services.

Respite Care Services — Direct care services needed because of a person's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Responsible Adult — An adult, as defined by Texas Family Code §101.003, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is age 18 years or older, the responsible adult must be the participant's managing conservator or legal guardian.

Responsible Party — A person who:

  • assists and/or represents an individual, applicant or member in the application or eligibility redetermination process; or
  • is familiar with the individual, applicant or member and his or her financial affairs and functional condition.

Service Area — The counties included in any HHSC-defined service area as applicable to each MCO.

Service Coordinator — The MCO staff person with primary responsibility for providing service coordination and care management to STAR Kids and STAR+PLUS members.

Service Provider (a.k.a. Employee) — A person who is hired, trained and managed by the employer to provide services authorized by the MCO.

Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the person providing PAS. The member decides how services are provided. It leaves the business details to a provider of the member's choosing.

Social Security Administration (SSA) — A federal agency that administers the social insurance programs in the U.S and authorizes Medicaid and waiver services.

Suspension — A temporary cessation of any waiver service without the loss of Medicaid or program eligibility.

State of Texas Access Reform (STAR) — STAR managed care program that operates under a federal waiver and primarily provides, arranges for, and coordinates preventive, primary, acute care, and pharmacy services for low-income families, children, and pregnant women.

STAR Health — The managed care program that operates under the Medicaid state plan and primarily serves:

  • children and youth in Texas Department of Family and Protective Services (DFPS) conservatorship;
  • young adults who voluntarily agree to continue in a foster care placement (if the state as conservator elects to place the child in managed care); and
  • young adults who are eligible for Medicaid as a result of their former foster care status through the month of their 21st birthday.

STAR Kids — Authority granted to the state of Texas to allow delivery of LTSS and acute care services to children and young adults with disabilities under the age of 21. The STAR Kids program assists members to live in the community in lieu of an NF.

STAR+PLUS Home and Community Based Services (HCBS) program — Authority granted to the state of Texas to allow delivery of community-based LTSS to adults with disabilities over the age of 21. The STAR+PLUS program assists members to live in the community in lieu of an NF.

STAR+PLUS program — The STAR+PLUS Medicaid managed care program in which HHSC contracts with MCOs to provide, arrange, and coordinate preventive, primary, acute and long term care covered services to adult persons with disabilities and elderly persons age 65 and over who qualify for Medicaid through the SSI program and/or the MAO program. Children under age 21, who qualify for Medicaid through the SSI program, may voluntarily participate in the STAR+PLUS program. The STAR+PLUS program is the umbrella designation that includes both the STAR+PLUS services and STAR+PLUS HCBS program.

STAR+PLUS Program Specialist — The staff person responsible, along with MCCO, for STAR+PLUS policy development.

State Plan — The agreement between the CMS and HHSC regarding the operation of the Texas Medicaid program, in accordance with the requirements of Title XIX of the Social Security Act.

Supplemental Security Income (SSI) — A federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind and disabled people with little or no income by providing cash to meet basic needs for food, clothing and shelter.

Support Advisor — An employee who provides support consultation to an employer, a DR, or a member receiving services through the CDS Option.

Support Consultation — An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.

Supported Employment (SE) — Services that assist the member with sustaining competitive employment or self-employment.

Transition Assistance Services (TAS) Agency — An agency that provides a one-time service to a Medicaid-eligible resident of an NF located in Texas to assist the resident in moving from the NF into the community.

Termination — Closure of an ongoing case due to a finding of ineligibility.

Texas Administrative Code (TAC) — A compilation of all the state rules in Texas that implement state programs and services.

Texas Health and Human Services Commission (HHSC) — Administrative agency within the executive department of the state of Texas established under Texas Government Code §531. HHSC is the single state agency charged with administration and oversight of the Texas Medicaid program, including Medicaid managed care.

Texas Home Living (TxHmL) — The Texas Home Living Program, operated by HHSC and approved by CMS in accordance with 1915(c) of the Social Security Act, that provides community-based services and supports to eligible people who live in their own homes or in their family homes.

Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid provider enrollment and fee-for-service (FFS) claims processing. TMHP is responsible for processing the STAR Kids Screening and Assessment Instrument (SK-SAI) for MDCP and the Medical Necessity and Level of Care (MN/LOC) assessment for the STAR+PLUS HCBS program.

Third-Party Resource (TPR) — Any person, entity or program that is, or may be, liable to pay for, or provide, any medical assistance or supports to a recipient under the approved Medicaid state plan, or as part of their caregiving arrangement without pay.

Texas Health Steps (THSteps) — The EPSDT benefit in Texas.

Texas Health Steps-Comprehensive Care Program (THSteps-CCP) — THSteps is also known as the EPSDT service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for Medicaid-eligible recipients from birth through age 20, including MDCP members. THSteps is dedicated to:

  • expanding recipient awareness of existing medical, dental and case management services through outreach and informing efforts; and
  • recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and case management services.

TxMedCentral — A secure internet bulletin board the state and MCOs use to share PII and PHI.

Unlicensed Assistive Person (UAP) — A paraprofessional who assists individuals, applicants or members with physical disabilities, mental impairments, and other health care needs with their ADLs, and provides bedside care. A UAP may perform nursing tasks only in specific situations, as governed by the Title 22 TAC §224 and Title 22 TAC §225.

Upgrade — An existing STAR+PLUS member who requests STAR+PLUS HCBS program services, or if the MCO determines the member would benefit from the STAR+PLUS HCBS program and is granted services after meeting waiver eligibility criteria.

Utilization Review (UR) — A formal assessment of the medical necessity, efficiency or appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.

Value-added Service (VAS) — A service provided by an MCO that is not "medical assistance," as defined by §32.003 of the Texas Human Resources Code. 

Forms

ES = Spanish version available.

FormTitle 
1579Referral for Relocation ServicesES
1581Consumer Directed Services OverviewES
1582Consumer Directed Services ResponsibilitiesES
1582-SROService Responsibility Option Roles and ResponsibilitiesES
1583Employee Qualification RequirementsES
1584Consumer Participation ChoiceES
1585Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed ServicesES
1586Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
1740Service Backup PlanES
1741Corrective Action PlanES
2128120 Day NoticeES
2406Physician Recommendation for Length of Stay in a Nursing FacilityES
2416Minor Home Modifications and Adaptive Aids Service Authorization 
2442Notification of Interest List Release ClosureES
2601Physician CertificationES
2602Application AcknowledgmentES
2603STAR Kids Individual Service Plan (ISP) NarrativeES
2604STAR Kids Individual Service Plan - Service Tracking ToolES
2606Managed Care Enrollment Processing DelayES
4801State Fair Hearing Evidence Packet Cover PageES
H1097Affidavit for Citizenship/IdentityES
H1200Application for Assistance – Your Texas Benefits 
H1746-AMEPD Referral Cover Sheet 
H1746-BBatch Cover Sheet 
H1826Case Information Release 
H2053-BHealth Plan SelectionES
H2065-DNotification of Managed Care Program ServicesES
H2067-MCManaged Care Programs Communication 
H3034Disability Determination Socio-Economic ReportES
H3035Medical Information Release/Disability DeterminationES
H3676Managed Care Pre-Enrollment Assessment Authorization 
H4800Fair Hearing Request Summary 
H4800-AFair Hearing Request Summary (Addendum) 
H4803Notice of Hearing 
H4807Action Taken on Hearing Decision 

23-4, Miscellaneous Changes

Revision Notice 23-4; Effective Aug. 21, 2023

The following sections were revised in the STAR Kids Program Support Unit Operational Procedures Handbook:

SectionTitleChange
1210Medical Necessity DeterminationClarifies Program Support Unit (PSU) staff’s role for the STAR Kids individual service plan (SK-ISP) cost limit. 
1210.2Medical Necessity Approval Time Frame for Initial Eligibility DeterminationsAdds new section about medical necessity (MN) approval time frame for initial eligibility determinations.
1614Verifying the Identity of an Applicant, Member, LAR, AR or Third Party IndividualChanges section title to Establishing Identity.
1614.1Telephone Communication Clarifies PSU staff processes for verifying phone communication. Changes section title to Phone Communication.
1615Information That May Be DisclosedClarifies PSU staff procedures for processing Form H1826, Case Information Release. 
1810Program Support Unit Staff Notification RequirementsUpdates PSU staff notification requirements.
2002Medical Necessity DeterminationClarifies PSU staff’s role regarding the SK-ISP cost limit.
2002.2Medical Necessity Approval Time Frame for Initial Eligibility DeterminationsAdds new section for MN approval time frame for initial eligibility determinations.
3210.2Reassessment of Medical Necessity DeterminationClarifies PSU staff’s role regarding the SK-ISP cost limit.
3325Reserved For Future UseAdds new section.
3328Reassessment Notification RequirementsUpdates PSU staff notification requirements.
3430Transfer from MDCP to Another Medicaid Waiver ProgramClarifies PSU staff notification requirements for the Medically Dependent Children Program (MDCP) member transfers to another 1915(c) waiver program. 
7000Applicant or Member Complaints and State Fair HearingsChanges section title to Applicant or Member Appeal Requests and State Fair Hearings. 
7100Reserved for Future UseChanges section title to Appeals and State Fair Hearings. Adds Texas Administrative Code (TAC) language and definitions.
7210Program Support Unit Staff Procedures for Completing Form H4800Changes section title to Entering a State Fair Hearing In TIERS. Updates PSU staff procedures for entering a fair hearing in the Texas Integrated Eligibility Redesign System (TIERS).
7214Changes to the State Fair Hearing Request SummaryUpdates PSU staff procedures for submitting fair hearing changes.
7221Type of DenialsClarifies PSU staff procedures for processing a fair hearing.
7221.1Medical Necessity Denial by Texas Medicaid & Healthcare PartnershipClarifies PSU staff procedures for supplemental security income (SSI) denials or terminations.
7221.3Supplemental Security Income Denial by the Social Security AdministrationRemoves section.
7221.4Other Denial ReasonsClarifies PSU staff procedures for other denial or termination reasons.
7222.1Continuation of Medically Dependent Children Program Services During a State Fair HearingClarifies PSU staff procedures for continuing MDCP during a fair hearing.
7233State Fair Hearing DecisionAdds fair hearing decision definitions.
7310Action Taken on the State Fair Hearing DecisionClarifies PSU staff procedure for processing fair hearing decisions.
7510Sustained State Fair Hearing Decision for ApplicantsAdds fair hearing decision definition for sustained fair hearing decision. Clarifies PSU staff procedure for processing a sustained fair hearing decision.
7510.1Sustained State Fair Hearing Decision for ApplicantsAdds new section.
7510.2Sustained State Fair Hearing Decision for Members With Continued MDCP BenefitsAdds new section.
7510.3Sustained State Fair Hearing Decision for Members Without Continued MDCP BenefitsAdds new section.
7511Sustained Decision – Termination Effective DateClarifies PSU staff procedure for processing a sustained fair hearing decision.
7520Reversed State Fair Hearing DecisionAdds fair hearing decision definition for reversed fair hearing decision. Clarifies PSU staff procedure for processing a reversed fair hearing decision.
7520.1Reversed State Fair Hearing Decision for ApplicantsAdds new section.
7520.2Reversed State Fair Hearing Decision for Members With Continued BenefitsAdds new section.
7520.3Reversed State Fair Hearing Decision for Members Without Continued BenefitsAdds new section.
7521Reversed Decision – Effective DateClarifies PSU staff procedure for processing a reversed fair hearing decision.
7600Roles and Responsibilities of Texas Health and Human Services Commission Hearings OfficerAdds TAC language.
Appendix XIHHSC Benefits Portal and TIERS Reference GuidesChanges appendix title. Includes additional reference guides.
Appendix XXIVFair Hearing and Interest List Options for MDCP Denials - MembersCorrects links and text.
Appendix XXIXFair Hearing and Interest List Options for Aging Out of MDCPUpdates PDFs on landing page and bolding in PDF.
Appendix XXVIIFair Hearing Options for MDCP Denials - ApplicantsUpdates PDFs on landing page and bolding in PDF.
Form 2128 InstructionsForm 2128 InstructionsCorrects miscellaneous content.

23-3, Miscellaneous Changes

Revision Notice 23-3; Effective May 22, 2023

The following sections were revised in the STAR Kids Program Support Unit Operational Procedures Handbook:

SectionTitleChange
1220Individual Cost LimitAdds clarifying language about Utilization Review (UR).
1270Financial EligibilityAdds Form 2606 references and removes Form H2065-D denial reason language.
1420Service Coordination and Programs Serving Members with Intellectual or Developmental DisabilitiesReserves section for future use.
1430Service Coordination and the Youth Empowerment Services Waiver ProgramReserves section for future use.
1440Service Coordinators and Home and Community Based Services - Adult Mental HealthReserved for Future Use. Removes personal needs allowance language.
2410Traditional Money Follows the PersonAdds clarifying language about Money Follows the Person process.
2412.4Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit CoordinationAdds clarifying language about the Money Follows the Person process.
2412.5Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: DenialsAdds clarifying language about the Money Follows the Person process.
2413.4Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Staff CoordinationAdds clarifying language about the Money Follows the Person process.
2413.5Traditional Money Follows the Person STAR Kids Nursing Facility Residents: DenialsAdds clarifying language about the Money Follows the Person process.
2414MDCP Money Follows the Person Delays in NF Discharge.Adds clarifying language about the Money Follows the Person process.
3300Member Service Planning and AuthorizationClarifies member service planning process.
3310Service PlanningClarifies member service planning process.
3311Updates to Individual Service PlanRemoves section.
3320Service Planning for Medically Dependent Children Program ServicesClarifies MDCP service planning process.
3321Medically Dependent Children Program Individual Service Plan RevisionClarifies MDCP service planning process.
3322Medically Dependent Children Program Individual Service Plan and Budget RevisionReserves section for further use.
3323Setting Aside Funds in the Medically Dependent Children Program Individual Service PlanReserves section for further use.
3325Multiple Medically Dependent Children Program Members in the Same HouseholdRemoves section.
3500Transition from Medically Dependent Children Program to Adult ProgramsUpdates title. Adds clarifying information about transitions to adult programs.
3510Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECCRenames Section. Adds clarifying information about transitions to adult programs.
3511Twelve Months Prior to the Member’s 21st BirthdayRemoves section.
3512STAR+PLUS Transition ActivitiesRemoves section.
3513Intrapulmonary Percussive Ventilator BenefitRemoves section.
6300.9Failure to Meet Other Program RequirementsRenames section title to, No Longer Meets the Age Requirement for MDCP, and includes denial processes for MDCP members transitioning to adult programs. 
6300.10Other ReasonsAdds miscellaneous updates.
7213State Fair Hearing Evidence PacketAdds Form 4801 references.
7222.2Termination of MDCP Services Due to a Member Not Requesting a State Fair HearingChanges section title to, Discontinuation of MDCP Services Due to Member Not Requesting a State Fair Hearing. Adds clarifying language. Changes time frame in which PSU staff will upload the state fair hearing evidence packet.
7231Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits PortalChanges section title to, Uploading the State Fair Hearing Evidence Packet. Adds clarifying language. Changes time frame in which PSU staff will upload the state fair hearing evidence packet.
7520Reversed State Fair Hearing DecisionUpdates PSU staff time frame for generating Form H2065-D and adds clarifying language.
Appendix IIForm H2065-D MDCP Reason for Denial and Comments LanguageAdds denial reason and comments language.
Appendix IX STAR Kids TxMedCentral Naming ConventionsCorrects naming conventions.
Appendix XVIIISTAR Kids HEART Naming ConventionsUpdates and adds HEART naming conventions.
Appendix XXIReserved for Future UseUpdate section title to, Creating an Appeal in TIERS. Adds information on creating an appeal in TIERS.
Appendix XXXCounty Codes and City and County ListAdds new appendix to house county codes, city codes and a list of counties.
Form 2128120 Day NoticeAdds form to handbook.

23-2, Miscellaneous Changes

Revision Notice 23-2; Effective April 1, 2023

The following section was revised in the STAR Kids Program Support Unit Operational Procedures Handbook: 

SectionTitleChange
Appendix XVIIISTAR Kids HEART Naming ConventionsUpdates and adds HEART naming conventions.
Appendix XXIVFair Hearing and Interest List Release Options - MembersUpdates section title. Changes fair hearing request time frame to 90 days. 
Appendix XXVIIFair Hearing Options for MDCP Denials - ApplicantsUpdates section title. Changes fair hearing request time frame to 90 days.
Appendix XXIXFair Hearing and Interest List Options for Aging Out of MDCPAdds a new appendix for fair hearing and interest list options for members who are transitioning out of MDCP.

23-1, Miscellaneous Changes

Revision Notice 23-1; Effective Jan. 16, 2023

The following section was revised in the STAR Kids Program Support Unit Operational Procedures Handbook: 

SectionTitleChange
Appendix XIVState Cutoff DatesUpdates with 2023 cut off dates.