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(link is external). Title 1 Texas Administrative Code (TAC) §353(link is external), 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)(link is external) 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 18-0; Effective September 4, 2018

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

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

  • have an approved medical necessity (MN) for an NF level of care (LOC);
  • have an individual service plan (ISP) with services under the established cost limit;
  • have an unmet need for at least one MDCP service;
  • be birth through age 20;
  • be a U.S. citizen and resident of Texas;
  • live in an appropriate living situation; and
  • have full Medicaid eligibility.

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

 

1210 Medical Necessity Determination

Revision 21-10; Effective October 25, 2021
 
A Medically Dependent Children Program (MDCP) applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before admission into the MDCP. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The applicant’s or member’s individual service plan (ISP) cost limit is calculated based on the information gathered through the SK-SAI MDCP module.

The managed care organization (MCO) completes and submits the SK-SAI to Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care Online Portal (LTCOP) for MDCP applicants or members. The SK-SAI for applicants requires a physician’s signature on Form 2601, Physician’s Certification, attesting the applicant meets the criteria to reside in an NF setting. For applicants, the MCO must obtain the physician’s signature on Form 2601 before submitting the SK-SAI to the TMHP LTCOP.

TMHP processes the SK-SAI to determine MN and calculate an alphanumeric three-digit Resource Utilization Group (RUG) value. A RUG value is a measure of NF staffing intensity and is used in MDCP to:

  • categorize needs for applicants or members; and
  • establish the STAR Kids Individual Service Plan (SK-ISP) cost limit.

An SK-SAI with a "BC1" RUG value error code indicates TMHP is not able to accurately determine MN or calculate the RUG value.  A “BC1” RUG error code is invalid and cannot be used to determine MDCP eligibility.

The MCO must inactivate and submit the corrected SK-SAI to the TMHP LTCOP within 14 days of submitting an SK-SAI that resulted in a “BC1” RUG value error code.

Program Support Unit (PSU) staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist when a medical assistance only (MAO) applicant meets MN and an SK-ISP has been received. PSU staff must indicate the start of care (SOC) for the MDCP program on Form H1746-A.

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

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

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

Revision 21-10; Effective October 25, 2021

The managed care organization (MCO) must complete and submit the STAR Kids Screening and Assessment Instrument (SK-SAI) to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A. The SK-SAI must accompany the signed Form 2601, Physician’s Certification. TMHP processes the SK-SAI to determine medical necessity (MN) and calculate an alphanumeric three-digit Resource Utilization Group (RUG) value.

 

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

Revision 21-10; Effective October 25, 2021

The managed care organization (MCO) must complete and submit the STAR Kids Screening and Assessment Instrument (SK-SAI) to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) following the receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A. The SK-SAI must accompany the signed Form 2601, Physician’s Certification. TMHP processes the SK-SAI to determine MN and calculate an alphanumeric three-digit Resource Utilization Group (RUG) value.

 

1220 Individual Cost Limit

Revision 18-0; Effective September 4, 2018

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

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

 

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

Revision 18-0; Effective September 4, 2018

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

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

 

1240 Age

Revision 18-0; Effective September 4, 2018

To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

 

1250 Citizenship and Identity Verification

Revision 18-0; Effective September 4, 2018

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long term services and supports (LTSS) members whose financial eligibility is based on a determination from the Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Verification of citizenship and identity for Medically Dependent Children Program (MDCP) eligibility purposes is a one-time activity conducted by Medicaid for the Elderly and People with Disabilities (MEPD), as documented in the MEPD 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 18-0; Effective September 4, 2018

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

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

1300, STAR Kids Services and Service Delivery Options

Revision 18-0; Effective September 4, 2018

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

 

1310 Acute Care Services

Revision 18-0; Effective September 4, 2018

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

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

Revision 18-0; Effective September 4, 2018

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

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

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

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

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

 

1430 Service Coordination and the Youth Empowerment Services Waiver Program

Revision 18-0; Effective September 4, 2018

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

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

 

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

Revision 18-0; Effective September 4, 2018

The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves members who have serious and persistent mental illness (SPMI) and:

  • a history of extended (three cumulative or consecutive years of the past five) institutional stays in psychiatric facilities;
  • severe mental illness (SMI) and frequent visits to the emergency department; and
  • SMI and frequent arrests and stays in a correctional facility.

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

 

1441 Program Point of Contact

Revision 18-0; Effective September 4, 2018

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

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

Revision 18-0; Effective September 4, 2018

 

1614.1 Telephone Communication

Revision 18-0; Effective September 4, 2018

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

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

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

 

1614.2 In-Person Communication

Revision 18-0; Effective September 4, 2018

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

  • 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 18-0; Effective September 4, 2018

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

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

  • Form 1826-D, Case Information Release; or
  • a document containing all of the following information:
    • the applicant or member’s:
      • full name (including middle initial) and Medicaid identification (ID) number; or
      • full name (including middle initial) and either date of birth (DOB) or Social Security number (SSN);
    • a description of the information to be released. Note: If a general release is authorized, provide the information that can be disclosed to the applicant, member, LAR or AR. Withhold confidential information from the case record, such as names of persons who disclosed information about the household without the household’s knowledge, and the nature of pending criminal prosecution;
    • a statement specifically authorizing HHSC or the MCO to release the information;
    • the name of the person or agency to whom the information will be released;
    • the purpose of the release;
    • an expiration event that is related to the member, the purpose of the release or an expiration date of the release;
    • a statement about whether refusal to sign the release affects eligibility for delivery of services;
    • a statement describing the applicant or member’s right to revoke the authorization to release information;
    • the date the document is signed; and
    • the signature of the applicant, member, LAR or AR.

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

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

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

 

1616 Verification and Documentation of Disclosure

Revision 18-0; Effective September 4, 2018

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

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

  • 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 18-0; Effective September 4, 2018

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

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

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

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

 

1820 Managed Care Organization Notification Requirements 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 Eligibility

Revision 21-10; Effective October 25, 2021

Title 1 Texas Administrative Code (TAC) §353.1155 applies to Medically Dependent Children Program (MDCP) services provided under a Medicaid managed care program. The managed care organization (MCO) must assess an individual’s functional eligibility for MDCP. To be eligible for MDCP, an individual must:

  • be under 21 years of age;
  • be a U.S. citizen and reside in Texas;
  • meet the level of care (LOC) criteria for medical necessity (MN) for nursing facility (NF) care as determined by 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 service;
  • not be receiving Community Care for the Aged and Disabled (CCAD) services;
  • choose MDCP as an alternative to nursing facility services, as described in 42 CFR §441.302(d);
  • not be enrolled in one of the following Medicaid Home and Community Based Services (HCBS) waiver programs:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS);
    • Texas Home Living (TxHmL); or
    • Youth Empowerment Services (YES); and
  • live in:
    • the individual’s home; or
    • an agency foster home as defined in the Texas Human Resource Code §42.002, (relating to Definitions); and
  • be determined by HHSC to be financially eligible for Medicaid, as described in Title 1 TAC §358 (relating to Medicaid Eligibility for the Elderly and People with Disabilities), and Title 1 TAC §361 (relating to Medicaid Buy-In for Children Program).

An individual receiving Medicaid NF services is approved for MDCP if the individual requests services while residing in an NF and meets the eligibility criteria listed above. If an individual is discharged from an NF into a community setting before being determined eligible for Medicaid, NF services and MDCP, the individual is denied immediate enrollment in the program.

HHSC maintains a statewide interest list of individuals interested in receiving services through MDCP. An individual or legally authorized representative (LAR) may request an individual's name to be added to the MDCP interest list by:

  • calling HHSC toll-free at 877-438-5658;
  • submitting a written request to HHSC; or
  • generating a referral through the YourTexasBenefits.com, Find Support Services screening and referral tool.

The ILM Unit will add an individual’s name to the MDCP interest list as requested above:

  • if the individual is a Texas resident; and
  • using the date HHSC receives the request as the MDCP interest list date.

HHSC removes an individual's name from the MDCP interest list if:

  • the individual is deceased;
  • the individual is assessed for MDCP and determined to be eligible or ineligible;
  • the individual or LAR requests the removal of the individual's name from the interest list; or
  • the individual moves out of Texas, unless the individual is a military family member living outside of Texas as described in Texas Government Code §531.0931:
    • while the military member is on active duty; or
    • for less than one year after the former military member's active duty ends.

An individual or LAR may request placement at the bottom of the interest list immediately following a determination of ineligibility for MDCP.

The MCO develops a person-centered STAR Kids Individual Service plan (SK-ISP) for each member enrolled in MDCP. All applicable documentation, as described in the STAR Kids Handbook (SKH), the Uniform Managed Care Manual (UMCM) and managed care contracts, must be in the member’s case file maintained by the MCO. The SK-ISP must:

  • include services described in the waiver;
  • include services necessary to protect the member's health and welfare in the community;
  • include services that supplement rather than supplant the member's natural supports and other non-MDCP supports and services for which the member may be eligible;
  • include services designed to prevent the member's admission to an institution;
  • include the most appropriate type and amount of services to meet the member's needs in the community;
  • be reviewed and revised if a member's needs or natural supports change or at the request of the member or LAR;
  • be approved by HHSC; and
  • be under the annual cost limit.

The MCO must submit a request for a clinical assessment to HHSC if a member's SK-ISP exceeds 50 percent of the cost of the member's LOC in a NF to safely serve the member's needs in the community.

HHSC Utilization Review (UR) may request a clinical review of the case to consider the use of state general revenue funds to cover costs exceeding 50 percent of the cost limit. HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit (PSU) if a clinical review is conducted. PSU staff must refer to Section 3324, Individual Service Plan Exceeding Cost Limit for MDCP Services, for information about exceeding the MDCP cost limit.

The MCO is responsible for conducting initial assessments, reassessments and developing the SK-ISP to determine eligibility for MDCP. The MCO must follow the policies and procedures outlined in the SKH, UMCM, managed care contracts and materials designated by HHSC.

A member participating in MDCP has the same rights and responsibilities as an individual enrolled in managed care, as described in Title 1 TAC §353, Subchapter C  (relating to Member Bill of Rights and Responsibilities), including the right to appeal a decision made by HHSC or an MCO and the right to a fair hearing, as described in Title 1 §357, Subchapter A , of this title (relating to Uniform Fair Hearing Rules). HHSC conducts utilization reviews of STAR Kids MCOs as described in Texas Government Code §533.00281.

 

2002 Medical Necessity

Revision 21-10; Effective October 25, 2021

Title 26 Texas Administrative Code (TAC) §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 that MN exists, an individual must meet the following conditions:

  • 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 a licensed nurse’s supervision, assessment, planning and intervention that are available only in an institution; and
  • 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.

 

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 18-0; Effective September 4, 2018

Financial eligibility for an individual with a qualified income trust (QIT) is determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. The MEPD specialist provides information to the individual about maintaining the QIT to remain eligible for Medicaid. A trustee is designated to manage the QIT and disburse payment to service providers on behalf of the member. The individual is informed that any funds deposited into the trust must be used toward the copayment for the cost of services delivered. The MEPD specialist will calculate the amount of income available from the trust for copayment and use the MEPD Communication Tool to provide the amount to Program Support Unit (PSU) staff. PSU staff must upload the MEPD specialist’s determination in the HEART case record. PSU staff must notify the managed care organization (MCO) 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, noting the copayment amount.

For an individual who is financially eligible based on a QIT, the eligibility based on the individual service plan (ISP) cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment are used to purchase §1915(c) Medicaid waiver services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of §1915(c) Medicaid waiver eligibility. The MCO must ensure the individual meets the initial ISP cost limit requirement before deducting the copayment. If the MCO does not properly establish this plan of care and the member’s cost exceeds the individual limit, the MCO must continue to provide Medically Dependent Children Program (MDCP) services to the member at the MCO’s expense. The MCO may not terminate MDCP services if a member exceeds his or her cost limit on the ISP.

The ISP is developed by the MCO without consideration of the trust. If the individual is eligible for MDCP within the cost limit, the copayment is allocated to purchase MDCP services identified on the electronic Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool. The ISP total and the amount of the provider service authorizations are reduced by the amount of the copayment. The member must pay the provider(s) directly for the amount of services. The MCO must document the QIT in the ISP. Continuing Medicaid eligibility through the MDCP is contingent upon copayment to the provider(s).

 

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 Coordination for Program Denial

Revision 18-0; Effective September 4, 2018

If the applicant fails to meet any of the eligibility criteria for the Medically Dependent Children Program (MDCP), not related to financial eligibility, within two business days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, from the managed care organization (MCO) and Form H2067-MC, Managed Care Programs Communication, notifying Program Support Unit (PSU) staff of the program denial, PSU staff must:

  • manually complete Form H2065-D, Notification of Managed Care Program Services;
  • mail the original Form H2065-D to the individual, legally authorized representative (LAR) or authorized representative (AR);
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions;
  • for medical assistance only (MAO) applicants, fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and Persons with Disabilities (MEPD) specialist;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable case documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) and close the HEART case record using the appropriate closure code.

If the individual fails to meet financial eligibility criteria established by MEPD, within two business days of receiving notification through the MEPD Communication Tool, PSU staff must:

  • manually complete Form H2065-D;
  • mail the original Form H2065-D to the individual;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • document the closure date and reason in the CSIL database and close the record; and
  • upload all applicable documents to HEART and close the HEART case record using the appropriate closure code.

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 18-0; Effective September 4, 2018

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aging or have disabilities live in the most integrated setting possible. The PI Initiative is Texas’ response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when the:

  • state’s treatment professionals determine the placement is appropriate; and
  • affected persons do not oppose the treatment and placement and can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "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 §531.151, as amended by Senate Bill 368, 77th Legislature, Regular Session, 2001).

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with the Texas Health and Human Services Commission (HHSC). For NFs, permanency planners are contracted with EveryChild, Inc. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

In accordance with legislative direction, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another §1915(c) Medicaid waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other §1915(c) Medicaid waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care (LOC), as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. Refer to the STAR Kids Managed Care Contract, Section 8.1.15, for additional information.

The MCO must have a protocol for quickly assessing the needs of members who will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary personal care services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

  • determine the member’s assigned permanency planner;
  • contact the member’s assigned permanency planner within seven days of the member’s facility admission;
  • collaborate with the member, legally authorized representative (LAR) or authorized representative (AR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
  • contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC’s contracted permanency planner to work with the member and LAR or AR to review community based options; and
  • work with the member, LAR, AR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

An individual without Medicaid and not enrolled in STAR Kids, requesting MDCP services through the MFP option, must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. An individual cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. Program Support Unit (PSU) staff and the MCO must follow established time frames for processing an application for MDCP. PSU staff must authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For an individual who cannot reside in an NF for 30 days because he or she meets the medically fragile criteria, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP to meet the 30-day requirement. Reference Section 2420, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual.

 

2410.1 Non-STAR Kids Individuals Residing in a Nursing Facility

Revision 21-10; Effective October 25, 2021

The Texas Health and Human Services Commission (HHSC) contracts with EveryChild Inc., who acts as the designated individual’s permanency planner to assist an individual under age 21 in transitioning from a nursing facility (NF) to the community.

The individual’s permanency planner contacts the Interest List Management (ILM) Unit within two business days of the individual’s selection of Medically Dependent Children Program (MDCP) under traditional Money Follows the Person (MFP) to:

  • Notify HHSC that the individual has selected MDCP under the traditional MFP process; and
  • Update the address on the individual or legally authorized representative (LAR)’s file if needed.  

ILM Unit staff complete the following activities for individuals who are on the MDCP interest list and request to pursue the traditional 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;
  • 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 traditional MFP 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 two business days of the receipt of the MDCP interest list 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 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 LAR:
  • 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 are responsible for completing the following 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, 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 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, LAR or NF 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, LAR or NF 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 does 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 notate the applicant is requesting to pursue the MDCP traditional MFP process on Form H1746-A. 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 applicable:

  • 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, 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 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 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 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, indicating:
    • if the individual or applicant in has a current medical necessity (MN) by entering the Resource Utilization Group (RUG) value; and
    • the MN expiration date in Item 6, which is 365 days from the effective date of the current MN approval date indicated in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • 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 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 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
  • 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 MCO initiates contact with the individual, applicant or LAR to begin the assessment process within 10 business days of receipt of Form H3676. The MCO must perform the SK-SAI within 15 business days from contact with the individual, applicant or LAR. The MCO must submit the SK-SAI to the TMHP LTCOP within 72 hours of the assessment’s completion. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification.

The MCO must complete the SK-SAI within a total of 30 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral.

The MCO must submit the complete SK-SAI to TMHP 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 SK-ISP to the TMHP LTCOP or Form 2604 to TxMedCentral; and
  • Form H3676, Section B to TxMedCentral.

PSU staff must monitor TxMedCentral for receipt of the completed:

  • Form 2604, if applicable; and
  • Form H3676, Section B.

PSU staff must monitor the TMHP LTCOP for receipt of the completed SK-ISP.

The MCO must complete and submit the SK-SAI and SK-ISP or Form 2604 before NF discharge.

The MCO must upload Form H2067-MC to TxMedCentral, as needed, to notify PSU staff of the proposed NF discharge date.

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. PSU staff track all actions and communications in the HEART case record until all MDCP enrollment activities are complete.

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 2604; and
  • Form H3676, Section B.

PSU staff must fax Form H1746-A to notify the MEPD specialist within two business days of receipt of the approved SK-ISP or Form 2604 and the SK-SAI if Medicaid is still pending, if applicable. PSU staff must notate the following on Form H1746-A:

  • The applicant is requesting to pursue the MFP process;
  • The applicant has an approved MN; and
  • The applicant has an approved SK-ISP or Form 2604.

PSU staff must check TIERS to verify Medicaid eligibility.

PSU staff must complete the following activities within one business day of receipt of all MCO documentation required for MDCP eligibility, in addition to the MEPD specialist’s Medicaid eligibility determination:

  • Confirm MDCP eligibility by verifying the applicant:
    • is under age 21 in TIERS;
    • is a Texas resident in TIERS;
    • has Medicaid eligibility for MDCP in TIERS;
    • has an approved MN in the TMHP LTCOP;
    • has an SK-ISP or Form 2604 with a least one MDCP service;
    • has an SK-ISP or Form 2604 within the individual’s cost limit; and
  • Manually generate the initial Form H2065-D;
  • Mail the initial Form H2065-D to the applicant or LAR, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX; and
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII.

The MCO collaborates with the applicant, LAR and PSU staff to identify a proposed discharge date. The MCO must notify PSU staff of the discharge date, once determined, within two business days by uploading Form H2067-MC to TxMedCentral.

PSU staff must complete the following activities if any other entity provides a different discharge date than the date previously established by the MCO within two business days of notification:

  • Upload Form H2067-MC to TxMedCentral, following the instructions in Appendix IX; and
  • Advise the MCO on Form H2067-MC of the discrepant discharge date.

PSU staff manually or electronically generate the final Form H2065-D containing the start of care (SOC) date within one business day of the member’s discharge, and complete the following activities:

  • Mail the final Form H2065-D to the member or LAR, following the instructions in Appendix II;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
  • For MAO members, fax Form H2065-D and Form H1746-A to the MEPD specialist, indicating the SOC date;
  • Close the MDCP ILR in the CSIL database using the appropriate closure reason and date;
  • Email Enrollment Resolution Services (ERS) at ManagedCareEligibilityEnrollment@hhsc.state.tx.us, requesting enrollment effective the first of the month in which the discharge occurred. The email must include:
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request  (i.e., Money Follows the Person);
    • MN approval date;
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • MCO selection;
    • effective date of enrollment; and
    • Form H2065-D; and
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case 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 within two business days of notification the applicant does not meet MDCP eligibility:

  • Electronically generate Form H2065-D in the TMHP LTCOP if the applicant was denied for MN;
  • Manually generate Form H2065-D, following the instructions in Appendix II, 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, following the instructions in Appendix IX, if manually generated;
  • Fax Form H2065-D and Form H1746-A to the MEPD specialist for MAO members, if appropriate;
  • Close the MDCP interest list release in the CSIL database, using the appropriate closure reason and date;
  • 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 check TIERS to verify Medicaid eligibility. PSU staff must complete the following activities within two business days of verifying Medicaid financial ineligibility:

  • Manually generate Form H2065-D, following the instructions in Appendix II;
  • Mail the original Form H2065-D to the individual, applicant or LAR, following the instructions in Appendix II;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;  
  • Document the closure date and reason in the CSIL database and close the 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 deny eligibility for MDCP following the steps above if the applicant chooses to leave the NF before being determined eligible for MDCP.

 

2410.2 STAR Kids Member Residing in a Nursing Facility

Revision 18-0; Effective September 4, 2018

When a STAR Kids member is admitted to a facility, the managed care organization (MCO) service coordinator must do the following:

  • contact the contracted Texas Health and Human Services Commission (HHSC) permanency planner, EveryChild Inc., within seven days of the member’s admission;
  • coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process, if needed, including sharing the most recent STAR Kids Screening and Assessment Instrument (SK-SAI) tool and individual service plan (ISP);
  • perform a new SK-SAI tool for a significant change in status upon discharge, unless one is required sooner for the Medically Dependent Children Program (MDCP); and
  • update the member’s ISP to reflect changes in the SK-SAI tool, if applicable.

For requests to transition to the community under traditional Money Follows the Person (MFP) for a STAR Kids member, the member’s permanency planner is the designated party responsible for part of the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the member, family, legally authorized representative (LAR) or authorized representative (AR) as part of the permanency planning process;
  • lead the development of the member’s permanency plan;
  • coordinate with the MCO service coordinator in updating the member’s ISP, if applicable;
  • educate the member, LAR and AR on §1915(c) Medicaid waiver options, including MDCP; and
  • document the member’s choice of the §1915(c) Medicaid waiver program.

Once the member selects a §1915(c) Medicaid waiver program, the permanency planner will contact the Interest List Management (ILM) Unit staff within two business days to notify HHSC of the member’s §1915(c) Medicaid waiver selection under MFP, and update the address on file to that of the LAR or AR, if needed.

If the member, LAR or AR chooses a §1915(c) Medicaid waiver program other than MDCP, ILM Unit staff will verify the individual is on the interest list for the §1915(c) Medicaid waiver program selected and immediately release the member from the interest list in the Community Services Interest List (CSIL) database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will forward the request to the selected §1915(c) Medicaid waiver program. The permanency planner will work with the individual, LAR, AR, and selected §1915(c) Medicaid waiver program staff to ensure program eligibility, MCO selection, and transition to services in the community.

If the member, LAR or AR chooses MDCP, ILM Unit staff will verify the individual is on the interest list for MDCP and immediately release the individual from the interest list in the CSIL database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) within one business day of the request and assign to the appropriate Program Support Unit (PSU) staff to proceed with necessary case actions.

Within two business days of the referral from ILM Unit staff, PSU staff must:

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify the member has a Medicaid type of assistance (TOA) applicable to MDCP;
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating whether the member has a current medical necessity (MN) by entering the Resource Utilization Group (RUG) and expiration date in Item 6 retrieved from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal;
  • post Form H3676 to TxMedCentral in the MCO STAR Kids folder; and
  • upload Form H3676 to the HEART case record.

The MCO initiates contact with the member, LAR or AR to begin the assessment process within 10 business days of receipt of Form H3676.

Within 15 business days from contact with the member, LAR or AR, the MCO service coordinator performs the SK-SAI, including the NCAM module and record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG. The MCO service coordinator must submit the SK-SAI to TMHP by posting to TxMedCentral within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the member meets MN, the service coordinator, in conjunction with the permanency planner, member, LAR and AR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determine a discharge date from the NF. The MCO service coordinator must submit the electronic Form 2604 to the TMHP LTC Online Portal within one business day of completion.

As needed, PSU staff collaborates with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays. PSU staff must track all actions and communications in the HEART case record until all MDCP enrollment activities are complete.

If within 30 days after the member’s, LAR’s or AR’s request to return to the community the MCO has not completed the MN process and submitted the ISP, PSU staff must email Managed Care Compliance & Operations (MCCO) staff to advise of the delay. PSU staff will continue to monitor TxMedCentral for receipt of Form H3676 or Form H2067-MC, Managed Care Programs Communication.

Within one business day following receipt of Form H2067-MC from the MCO, PSU staff must:

  • confirm MDCP eligibility by verifying 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 an ISP with at least one MDCP service;
    • has an ISP that is within the individual’s cost limit; and
    • has an appropriate Medicaid TOA in TIERS.
  • generate the initial Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTC Online Portal;
  • mail the initial Form H2065-D to the member; and
  • upload Form H2065-D, Form 2604, and Form H2067-MC to the HEART case record.

Within one business day prior to the member’s discharge from the NF, PSU staff must:

  • generate the final Form H2065-D in the TMHP LTC Online Portal containing the service effective date;
  • mail the original Form H2065-D to the member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions;
  • document the closure date and reason in the CSIL database and close the record; and
  • upload Form H2065-D to the HEART case record.

If MDCP eligibility is denied, PSU staff must:

  • manually complete Form H2065-D;
  • mail the original Form H2065-D to the member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • upload Form H2065-D, Form 2604, and Form H2067-MC to HEART and close the HEART case record using the appropriate closure code; and
  • document the closure date and reason in the CSIL database and close the record.

 

2410.3 MDCP Money Follows the Person Applications Pending Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with an individual who has community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge from a nursing facility (NF) that goes beyond a four month period, PSU staff should keep the request for services open.

Example: If an individual is anticipating an NF discharge on December 15, the four month period would end the last day of April.

Example: If an individual is anticipating an NF discharge on January 1, the four month period would end the last day of April.

An individual who has not made 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 should be denied Medically Dependent Children Program (MDCP). PSU staff deny the request for services and must:

  • mail Form H2065-D, Notification of Managed Care Program Services, to the individual within two business days after the end of the four calendar month pending period;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions; and
  • upload Form H2065-D and all other relevant documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) and close the HEART case record using the appropriate closure code.

 

2410.4 Money Follows the Person Demonstration (MFPD) References in STAR Kids

Revision 18-0; Effective September 4, 2018

Money Follows the Person Demonstration (MFPD) does not apply to an individual enrolled in the Medically Dependent Children Program (MDCP). Children will transition to the least restrictive setting under Money Follows the Person (MFP). Therefore, managed care organization (MCO) service coordinators will not be required to track the enrollment period or seek informed consent from the member, legally authorized representative (LAR) or authorized representative (AR). The "MFPD" check box should be disregarded 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

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.

 

3100.1 Medical Necessity

Revision 21-10; Effective October 25, 2021

Title 26 Texas Administrative Code (TAC) §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 that MN exists, an individual must meet the following 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.

 

3110 Assessment of Medical Necessity for Community First Choice

Revision 18-0; Effective September 4, 2018

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for members with a physical disability to be eligible for Community First Choice (CFC) services. STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. A physician certification is required for all initial assessments for MN for CFC services. Form 2601, Physician Certification, must be obtained by the MCO, maintained in the MCO member case file signed and dated by the member’s physician prior to the submission of the SK-SAI for initial assessments for CFC. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered "complete" when the physician certification is attached to the MCO member case file.

If an individual who is released from the MDCP interest list is receiving CFC services and has been determined to have MN within the last 365 days, the MCO completes the SK-SAI, including the MDCP module, but leaves Field Z5a as a “No” (indicated by a “0”). The MCO must note when the member’s MN expires and arrange for a reassessment with the member, legally authorized representative (LAR) or authorized representative (AR). A physician’s certification, Form 2601, is not required for a reassessment of MN.

If the MCO is assessing a member for CFC services for the first time, in addition to the required fields for MN, the MCO must complete the functional assessment for CFC services using the personal care assessment module (PCAM), including Section P, as well as questions in Section Z that assess for support management and Emergency Response Services (ERS). For a member to continue to be eligible for CFC services, a determination of MN is required every 12 months. If a previous physician certification is in the MCO member case file, a new certification is not needed.

If a member had a determination of MN approval within the last 365 days and requests CFC, the MCO completes the SK-SAI, including the PCAM and Section P, but leaves Field Z5a marked “No” (indicated by a “0”). The MCO must note when the member’s MN expires and arrange for a reassessment with the member, legally authorized representative (LAR) or authorized representative (AR). If a member meets MN and has a need for CFC services, the MCO prepares an individual service plan (ISP) for the member and provides an authorization to the network provider of the member, LAR or AR’s choice.

 

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for enrollment in the Medically Dependent Children Program (MDCP). STAR Kids managed care organizations (MCOs) must complete the required fields on the STAR Kids Screening and Assessment Instrument (SK-SAI) for a determination of MN and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP).

An applicant or member coming off the MDCP interest list must be assessed using the SK-SAI no later than 30 days following notification from Program Support Unit (PSU) staff, of the MCO selection as detailed in Section 2220, Managed Care Organization Coordination. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is considered complete when the physician’s signed and dated certification is on file with the MCO. MCOs assessing applicants or members for MDCP services must complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate “Yes” on Field Z5a (indicated by a "1") when seeking an MN determination from TMHP. A physician certification is required. Form 2601, Physician Certification, must be signed and dated by the physician and maintained by the MCO in the MCO member case file. Form 2601 must be signed and dated by the member’s physician prior to the submission of the SK-SAI when Field Z5a is marked “Yes” (indicated by a “1”) on initial assessments for MDCP.

Additional scenarios relating to MN determinations are available in the STAR Kids Project MCO Business Rules in Appendix I, MCO Business Rules for SK-SAI and SKI-ISP.

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 Reassessment of Medical Necessity or Level of Care

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI) no earlier than 90 days before, and no later than 30 days prior to, the expiration of the member’s current individual service plan (ISP) on file for members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services. The MCO must indicate “Yes” in Field Z5a (indicated by a “1”) to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the MCO member case file contains Form 2601 from a previous assessment and there has been no change to the member’s health status. The MCO must ensure the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for a psychiatric hospital or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member, legally authorized representative (LAR) or authorized representative (AR) to schedule a reassessment prior to the expiration of the member’s LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member’s ISP is completed by the MCO annually. PSU staff must search the TMHP Long Term Care (LTC) Online Portal for all ISPs submitted on a daily basis. Once an ISP is received, within five business days PSU staff must:

  • check the TMHP LTC Online Portal to determine if the MCO has electronically submitted Form 2604, STAR Kids Individual Service Plan Service Tracking Tool, before the ISP end date;
  • verify the member has an approved SK-SAI in the TMHP LTC Online Portal;
  • verify the ISP is within the cost limit in the TMHP LTC Online Portal;
  • confirm ongoing Medicaid eligibility and managed care enrollment is active in the Texas Integrated Eligibility Redesign System (TIERS); and
  • upload Form 2604 to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff do not manually complete or generate Form H2065-D, Notification of Managed Care Program Services, for approved reassessments. PSU staff do not mail Form H2065-D to the member for approved reassessments.

If the reassessment ISP is not submitted due to the member’s timely appeal of an MDCP denial, the individual’s services will continue using the existing ISP until a decision is received from the hearings officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and the SK-SAI is denied, the MCO must notify PSU staff of the denial by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting PSU staff to manually generate Form H2065-D. Form H2065-D is not generated in the TMHP LTC Online Portal at reassessment for denials; PSU staff must manually complete Form H2065-D. PSU staff mail Form H2065-D to the member and post Form H2065-D to the appropriate MCO STAR Kids folder in TxMedCentral, following the instructions in Appendix IX, Naming Conventions. See Section 3328, Reassessment Notification Requirements, for additional information.

3300, Member Service Planning and Authorization

Revision 18-0; Effective September 4, 2018

Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. For new Medically Dependent Children Program (MDCP) members, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). For existing MDCP members, the ISP must be completed within 60 days of completion of the SK-SAI at reassessment. The MCO must ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs and member preferences. The ISP must be used to communicate and help align expectations between the member, legally authorized representative (LAR), authorized representative (AR), MCO and key service providers. The STAR Kids individual service plan (ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member, LAR or AR, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The ISP is used for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the STAR Kids MCO;
  • documenting services received through third party sources, such as §1915(c) Medicaid waiver programs operated by the state;
  • identifying the member’s strengths, preferences, support needs and desired outcomes;
  • identifying what is important 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 and/or providers should know when supporting the member; and
  • documenting the member’s unmet needs.

For STAR Kids members receiving MDCP services, the ISP must fall within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a printed or electronic copy of the ISP to each member, LAR or AR following any significant update, and not less than annually, within five business days of meeting with the member, LAR or AR. The MCO must provide a copy of the ISP to the member’s providers and other individuals specified by the member, LAR or AR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member, LAR or AR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports (LTSS) no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member’s current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member’s MCO service coordinator, or a representative of the MCO, must review and update each member’s ISP with the member, LAR or AR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

 

3310 Service Planning

Revision 18-0; Effective September 4, 2018

All STAR Kids individual service plan (ISP) narratives must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. 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), authorized representative (AR) or others in the member’s support network, key service providers, the member’s health home, the managed care organization (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;
  • if applicable, services provided to the member through other §1915(c) Medicaid waiver programs not operated by the MCO or third-party resources (TPR), and the sources or providers of those services;
  • plans specifically related to transitioning to adulthood for members age 15 and older; and
  • any additional information to describe strategies to meet service objectives and member goals.

The ISP must be formed by findings from the SK-SAI, in addition to input from the member, family and caretakers, providers and any other individual with knowledge and understanding of the member’s strengths and service needs who is identified by the member, LAR, AR or the MCO. To the extent possible and applicable, the ISP must also account for school based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but must not require the member to provide, a copy of the member’s Individualized Education Plan (IEP).

The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week, begin/end date, and whether the member has chosen the Consumer Directed Services (CDS) option or Service Responsibility Option (SRO), if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by TPR, like Medicare or available community services. Form 2603 is updated, per Section 3311 below, and is maintained in the MCO member case file.
 

3311 Updates to the Individual Service Plan

Revision 18-0; Effective September 4, 2018

Each member’s individual service plan (ISP) must be updated at least annually, or sooner in the following situations outlined in the STAR Kids Managed Care Contract, Section 8.1.39.1:

  • upon discharge from an inpatient stay;
  • upon discharge from a long-term care facility;
  • upon a significant change in the member’s condition that results in a need for additional or reduced services;
  • upon notification of a significant change in life circumstance (change in family structure, a physical move or death in the family); and
  • within seven calendar days of the member’s request.

 

3320 Service Planning for Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) service coordinator must work with the member, legally authorized representative (LAR) or authorized representative (AR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member’s cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member’s Resource Utilization Group (RUG), which is determined based on the STAR Kids Screening and Assessment Instrument (SK-SAI). Cost limits associated with each RUG are found in Appendix VIII, RUG IPC Cost Limits.

The MCO service coordinator documents MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week, begin/end date, and whether the member has chosen the Agency Option (AO), Consumer Directed Services (CDS) option, or Service Responsibility Option (SRO), if applicable. Form 2603 must also include a brief rationale (i.e., why the service is needed or requested).

The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the MCO completes and submits the electronic ISP within 60 days of the initial referral from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic ISP within 60 days following receipt of a Texas Medicaid & Healthcare Partnership (TMHP) response to the SK-SAI submission. The response file from TMHP contains the determination of medical necessity (MN) and the member’s RUG. The start date for the ISP must be the first day of the month following the MN approval date. If a Medicaid eligibility determination is required, the start of care (SOC) date on the ISP is the first day of the month following the applicant meeting all eligibility criteria. An ISP is valid for one year.

When the member’s ISP is complete and within the member’s established cost limit, the MCO submits Form 2604 to the TMHP Long Term Care (LTC) Online Portal. The MCO must submit the electronic ISP prior to the start date of the member’s ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

If the member is turning age 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member’s cost limit. To calculate the prorated cost, the MCO must:

  • Step 1: divide the cost limit by the total number of days (365) in a year;
  • Step 2: determine the total number of days beginning with the start date of the ISP and ending the end of the month of the member’s 21st birthday; and
  • Step 3: multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the ISP period for which the member is eligible.

Example: The member’s 21st birthday is July 9, the ISP start date is April 1, and the end date will be on July 31. The member’s cost limit is $25,000.

  • Step 1: $25,000 ÷ 365 days = $68.49 per day.
  • Step 2: The number of days per month: April = 30, May = 31, June = 30, July 31, for a total of 122 days.
  • Step 3: $68.49 × 122 = $8,355.78.

$8,355.78 is the prorated cost limit for the individual for the ISP.

 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 18-0; Effective September 4, 2018

If a member, legally authorized representative (LAR) or authorized representative (AR) requests a change to the member’s Medically Dependent Children Program (MDCP) individual service plan (ISP), but the member has not experienced a change in condition that affects his Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request within 14 days.

To revise a member’s MDCP ISP when there is no change in the member’s RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and submits the ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal with the updated services and a revised begin date. The MCO maintains the updated Form 2603 in the MCO member case file.

 

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 18-0; Effective September 4, 2018

If a member, legally authorized representative (LAR), authorized representative (AR), service provider or service coordinator notify the managed care organization (MCO) about a change in the member’s condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the MCO must reassess the member within 14 days. The MCO must complete the STAR Kids Screening and Assessment Instrument (SK-SAI) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, including the Medically Dependent Children Program (MDCP) module, and complete the following fields according to Appendix I, MCO Business Rules for SK-SAI and SK-ISP:

  • A10c = Medicaid number of the individual
  • A12 = 2 (Significant Change in Status Reassessment)
  • Z5a = 0 (No)
  • Z5b = 0 (No)

Following the MCO receipt of a TMHP response file indicating the member’s new RUG and associated cost limit, the MCO completes a new STAR Kids individual service plan (ISP) that reflects the member’s, LAR’s or AR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member’s new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the MCO member case file.

If a member will turn age 21 between the start and end date of the member’s ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or Transition Assistance Services (TAS) are provided prior to the end of the month of the member’s 21st birthday. If the MCO authorizes adaptive aids, minor home modifications or TAS, the MCO remains responsible for payment for those services, including applicable warranties.

 

3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan

Revision 18-0; Effective September 4, 2018

Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member, legally authorized representative (LAR) or authorized representative (AR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member, LAR or AR chooses to set aside funds, the MCO must document the member’s, LAR’s or AR’s preferences and maintain documentation in the MCO member case file. A member, LAR or AR may not carry forward funds between ISP periods.

 

3324 Individual Service Plan Exceeding the Cost Limit for MDCP Services

Revision 18-0; Effective September 4, 2018

If the individual service plan (ISP) cost exceeds 50 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits by email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

  • STAR Kids Screening and Assessment Instrument (SK-SAI);
  • STAR Kids individual service plan (ISP) and any Addendums; and
  • Medical records (nursing care plan, recent care notes, doctor’s orders and nursing notes).

HHSC UR may request a clinical review of the case to consider the use of state General Revenue (GR) funds to cover costs exceeding the 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and Program Support Unit (PSU) staff.

Note: MCOs must not discuss with applicants, members, legally authorized representatives (LARs) or authorized representatives (ARs), or request use of state GR funds for services above the cost ceiling.

 

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 18-0; Effective September 4, 2018

In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each member.

In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member’s care is based on his or her individual service plan (ISP) and all individuals’ needs are met.

Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.

 

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 Provider Procedures

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must ensure the member’s individual service plan (ISP) is authorized annually. PSU staff must search the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for all ISPs submitted on a daily basis. Once an ISP is received, within five business days PSU staff must:

  • check the TMHP LTC Online Portal to determine if the managed care organization (MCO) has submitted Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool,  before the ISP end date;
  • verify the member has an approved STAR Kids Screening and Assessment Instrument (SK-SAI) in the TMHP LTC Online Portal;
  • verify the ISP is within the cost limit in the TMHP LTC Online Portal; and
  • confirm ongoing Medicaid eligibility and managed care enrollment is active in the Texas Integrated Eligibility Redesign System (TIERS); and
  • upload Form 2604 to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff do not manually complete or generate Form H2065-D, Notification of Managed Care Program Services, for approved reassessments. PSU staff do not mail Form H2065-D to the member for approved reassessments.

If the reassessment ISP is not submitted due to the member’s timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual’s services will continue using the existing ISP until a decision is received from the hearings officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

 

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 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must mail Form H2065-D, Notification of Managed Care Program Services, at reassessment as notification of continuing services if the member continues to meet Medically Dependent Children Program (MDCP) requirements. PSU staff must complete the following activities for an approved MDCP reassessment within five business days of 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 or legally authorized representative (LAR); 
  • 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 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 Complaints, Internal MCO Appeals and State Fair Hearings, if the member files a state fair hearing within the adverse action notification period.

3400, Member Transfers

3410 Transfer from One Managed Care Organization to Another

Revision 18-0; Effective September 4, 2018

Once the initial enrollment period of one calendar month of service authorization has passed, a member is eligible to change managed care organization (MCO) plans. When a member, legally authorized representative (LAR) or authorized representative (AR) chooses to change from one MCO to another MCO in the same service area (SA), the member, LAR or AR must contact the state contracted enrollment broker by telephone at 800-964-2777 or via written correspondence.

The member can request to change MCOs as many times as the member wants, but the change cannot be made more than once per month. If the member calls to change the MCO on or before the 15th day of the month, the change will take place on the first day of the next month. If the member calls after the 15th day of the month, the change will take place the first day of the second month following the change request.

Examples:

  • If the member calls on or before April 15, the change will take place on May 1.
  • If the member calls after April 15, the change will take place on June 1.

Texas Health and Human Services Commission (HHSC) Operations prepares and sends the Monthly Plan Changes report to Program Support Unit (PSU) staff. PSU staff receive a full list and share MCO specific information with Managed Care Compliance & Operations (MCCO) staff by email. MCCO staff share the list with MCOs. The MCO receives a member-specific report that gives a list of STAR Kids members who have changed MCOs from the previous month.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information concerning the result of the MCO assessment upon the gaining MCO request. Within five business days of receiving the list of members changing MCOs, the gaining MCO must request any documentation in the MCO member case file from the losing MCO, such as the member’s Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. The gaining MCO must ensure the member’s new service coordinator, once assigned, contacts the member’s former service coordinator at the losing MCO to ensure a seamless transition of service coordination. The gaining MCO must contact the losing MCO for additional information maintained in the MCO member case file. If the gaining MCO experiences issues obtaining this information, the MCO must notify MCCO staff.

MCCO staff must contact the losing MCO and require the MCO to upload information contained in the MCO member file to TxMedCentral, including Form 2603 and any current authorizations, within two business days of notification. MCCO staff inform PSU staff by email, the date by which the MCO must upload the information to TxMedCentral. PSU staff transfer the information from the losing MCO to the gaining MCO within two business days of notification from MCCO staff. The STAR Kids Screening and Assessment Instrument (SK-SAI) and electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, as well as historical SK-SAIs and ISPs, will be available to the gaining MCO upon enrollment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within five business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 15 business days of enrollment of the new member, the gaining MCO must conduct a home visit to assess the member’s needs. For continuity of care, this includes authorizations, additional assessments, and pending delivery of adaptive aids, minor home modifications or Transition Assistance Services (TAS). This home visit may include conducting the SK-SAI if the member is due for a new assessment, has experienced a significant change in condition, or if otherwise deemed necessary by the gaining MCO. The gaining MCO must adhere to all rules for SK-SAI processing related to member transfers outlined in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member requires a new assessment or until the gaining MCO is able to complete its own SK-SAI, update the ISP, and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with his or her existing provider and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s needs. If the gaining MCO is in a different SA because the member moved, the gaining MCO assists the member in locating providers immediately upon request from the member, LAR or AR. Out-of-network authorizations must continue until the existing ISP expires or the gaining MCO can provide comparable services to transition the member to a provider that will be able to meet the member’s needs.

 

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 21-10; Effective October 25, 2021

Title 1 Texas Administrative Code (TAC) §353.1155(b)(1)(F) states Medically Dependent Children Program (MDCP) members cannot be enrolled in more than one 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.

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; and
  • is eligible for the IDD waiver program; or
  • is already enrolled with an IDD waiver program.

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

  • Create a case record in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART), if applicable;
  • Check if the member has an open enrollment with the IDD waiver program according to the procedures below:
    • For either TxHmL or HCS waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the member is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable.
    • For 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 Texas Integrated Eligibility Redesign System (TIERS) Long Term Services and Supports (LTSS) screen; and
  • Ensure the member is on the interest list for the requested IDD waiver program in the Community Services Interest List (CSIL) database, if the member is not already enrolled with an IDD waiver program;
  • Contact and coordinate with IDD waiver program staff, the member, legally authorized representative (LAR) and the MCO, as appropriate, to determine an MDCP termination date and a start of care (SOC) date for the IDD waiver program;
  • Terminate the STAR Kids Individual Service Plan (SK-ISP) one day prior to the member’s SOC date for the IDD waiver program in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • 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, 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”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., waiver transfer);
    • medical necessity (MN) approval date;
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • 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, STAR Kids HEART Naming Conventions;
  • Document all contacts with the IDD waiver program staff, member, LAR 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 18-0; Effective September 4, 2018

Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition services when they are age 15 and periodically meet with a transition specialist to plan their transition to adulthood. Members who receive Medically Dependent Children Program (MDCP) services, Private Duty Nursing (PDN), Community First Choice (CFC) or Personal Care Services (PCS) and are transitioning to adult programs may apply for services through STAR+PLUS, including the STAR+PLUS Home and Community Based Services (HCBS) program, in order to continue receiving community-based services and avoid institutionalization beginning the first day of the month following their 21st birthday.

 

3510 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018

Possible §1915(c) Medicaid waiver and service combinations the member may be receiving prior to transition:

  • Medically Dependent Children Program (MDCP) only;
  • private duty nursing (PDN) only;
  • Prescribed Pediatric Extended Care Center (PPECC) services only;
  • MDCP with either or both of the following services:
  • personal care services (PCS);
  • PDN/PPECC;
  • MDCP with Community First Choice (CFC) services;
  • PDN/PPECC with PCS; and
  • PDN/PPECC with CFC services.

 

3511 Twelve Months Prior to the Member’s 21st Birthday

Revision 21-10; Effective October 25, 2021

A member 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 age 21 years. Members enrolled in MDCP, PDN or PPECC are assessed for eligibility in the STAR+PLUS Home and Community Based (HBCS) program prior to age 21 years.  

The Utilization Review (UR) Unit staff provide a copy of the Comprehensive Care Program (CCP) Transition Report to the Program Support Unit (PSU) program manager quarterly. The CCP Transition Report lists members who are:

  • enrolled in STAR Kids;
  • receiving MDCP and/or PDN/PPECC and/or Community First Choice (CFC); and
  • may transition to STAR+PLUS HCBS program in the next 12 months.

Procedures for managing this report, including time frames, can be found in Appendix VI, STAR Kids Transition Activities.

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

The MCO must present an overview of the STAR+PLUS HCBS program and the changes that will take place the first of the month following the member’s 21st birthday during the home visit.

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

 

 

3512 STAR+PLUS Transition Activities

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff for the STAR+PLUS Home and Community Based Services (HCBS) program will follow the STAR+PLUS enrollment guidelines as outlined in the STAR+PLUS HandbookSection 3420, Individuals Transitioning to an Adult Program.

 

3513 Intrapulmonary Percussive Ventilator Benefit

Revision 18-0; Effective September 4, 2018

Intrapulmonary Percussive Ventilator (IPV) is not currently a benefit of Texas Medicaid, but Texas Health and Human Services Commission (HHSC) has approved IPVs in limited circumstances based on medical necessity (MN) criteria under the Comprehensive Care Program (CCP) on a case-by-case basis.

IPV is not a benefit of Texas Medicaid, with the following exceptions:

  • Children and young adults who have been approved for and are currently utilizing IPV in traditional Medicaid will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of the child/young adult when he transitions to a STAR Kids MCO.
  • When a member turns age 21 and transitions into STAR+PLUS, young adults who have been approved for and are currently utilizing IPV will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of a young adult. The member will not be subjected to an abrupt removal of equipment. The member will continue to receive ongoing treatment until the final decision is made, on a case-by-case basis, with thorough review and documentation by the managed care organization (MCO) and explicit approval by HHSC administration.
  • STAR Kids MCOs will address a new request for IPV on a case-by-case basis based on MN criteria for the member.

 

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 18-0; Effective September 4, 2018

This section outlines the delivery of STAR Kids community long term services and supports (LTSS). Sections 4100-4520 describe Medicaid state plan LTSS, assessment and reassessment requirements, and provider requirements.

Sections 4600-4922 describe services available to members receiving Medically Dependent Children Program (MDCP) services, service requirements, limitations and provider requirements.

4100, Community First Choice

Revision 18-0; Effective September 4, 2018

Community First Choice (CFC) is a group of services delivered under the authority of §1915(k) of the Social Security Act. CFC is under federal regulations governing home and community based services. Therefore, the settings in which CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) §441.301(c)(4) and Title 42 CFR §441.710, respectively. Permissible home and community based settings include member homes, apartment buildings and non-residential settings. Community based settings exclude:

  • nursing facilities (NFs);
  • hospitals providing long term care (LTC) services;
  • inpatient psychiatric facilities;
  • intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID); or
  • a setting on the grounds of, or with the characteristics of, an institution.

Provider owned and controlled settings are also excluded from CFC because those providers are paid for CFC-like services as part of the provider rates, and to provide CFC would be duplicative.

Assessment for CFC services and the development of a member’s service plan must be person-centered, per Title 42 CFR §441.540. STAR Kids managed care organizations (MCOs) may not require CFC providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for CFC services.

 

4110 Community First Choice Eligibility

Revision 18-0; Effective September 4, 2018

Eligibility for Community First Choice (CFC) requires a STAR Kids member to meet the following conditions:

  • be Medicaid eligible;
  • meet the level of care (LOC) provided in a hospital or nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or an institution providing psychiatric services; and
  • have an assessed functional need for CFC services.

All STAR Kids members are Medicaid eligible. Members whose eligibility is established due to eligibility for Youth Empowerment Services (YES) or the Medically Dependent Children Program (MDCP) are eligible for CFC services, per the Social Security Act §1902(a)(10)(A)(ii)(VI), as these members meet eligibility for an institution providing psychiatric or NF services. To maintain CFC eligibility, the managed care organization (MCO) must ensure the member receives at least one waiver service per month. A member may not be authorized to receive both personal care services (PCS) and CFC services at the same time.

Members who receive services through the following §1915(c) Medicaid waiver programs receive CFC services through their §1915(c) Medicaid waiver provider and are not eligible to receive CFC through the MCO:

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

 

4111 Determining Institutional Level of Care

Revision 18-0; Effective September 4, 2018

 

4111.1 STAR Kids Screening and Assessment Instrument

Revision 18-0; Effective September 4, 2018

For members with physical disabilities, the STAR Kids Screening and Assessment Instrument (SK-SAI) contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP), on behalf of the Texas Health and Human Services Commission (HHSC), to determine if an applicant or member meets medical necessity (MN) for the level of care (LOC) provided in a hospital or nursing facility (NF). Once the SK-SAI is completed, the managed care organization (MCO) must obtain the member’s physician’s signature on Form 2601, Physician Certification, certifying the applicant or member requires NF services or alternative community based services under the supervision of a physician.

Further information about the MN determination process for Community First Choice (CFC) may be found in Section 3110, Assessment of Medical Necessity for Community First Choice.

 

4111.2 Intellectual Disability or Related Condition Assessment

Revision 18-0; Effective September 4, 2018

Upon notification from the managed care organization (MCO), Local Intellectual or Development Disability Authorities (LIDDAs) conduct an intellectual disability or related condition (ID/RC) assessment to determine whether an applicant or member meets the level of care (LOC) provided by an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID). Medically Dependent Children Program (MDCP) members already have an established LOC for ICF/IID and do not require an ID/RC assessment. MDCP members will be assessed using the Community First Choice (CFC) module of the STAR Kids Screening and Assessment Instrument (SK-SAI). In addition to the ID/RC assessment, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if an applicant or member does not have a DID on file or the DID on file is determined to be outdated. The LIDDA submits this information to the Texas Health and Human Services Commission (HHSC) for a determination of ID/RC. HHSC notifies the LIDDA about the determination and the LIDDA notifies the applicant or member’s MCO. If an applicant or member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment and forwards the assessment to the applicant’s or member’s MCO. If the applicant or member does not agree to the CFC service plan, he or she may file an appeal with the MCO. If the applicant or member does not agree to the CFC service plan or refuses CFC services, the MCO must notify the LIDDA within 10 business days of the applicant or member refusing or ending CFC services.  
 

4111.3 Child and Adolescent Needs and Strengths or Adult Needs and Strengths Assessment

Revision 18-0; Effective September 4, 2018

A comprehensive provider of mental health rehabilitative services or a Local Mental Health Authority (LMHA) conducts the Child or Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and a licensed practitioner determines whether the applicant or member meets an inpatient psychiatric facility level of care (LOC). If the applicant or member meets that LOC, or receives services through Youth Empowerment Services (YES), the managed care organization (MCO) conducts the Community First Choice (CFC) functional assessment if the applicant or member requests CFC services.
 

4120 Community First Choice Services

Revision 18-0; Effective September 4, 2018

Community First Choice (CFC) services include personal assistance services (CFC-PAS), habilitation (CFC-HAB), Emergency Response Services (CFC-ERS) and support management.
 

4121 Community First Choice Personal Assistance

Revision 18-0; Effective September 4, 2018
 
Community First Choice personal assistance service (CFC-PAS) provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision and/or cueing. Such assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. CFC-PAS includes:

  • non-skilled assistance with the performance of ADLs and IADLs;
  • household chores necessary to maintain the home in a clean, sanitary and safe environment;
  • escort services, which consist of accompanying, but not transporting, and assisting a member to access services or activities in the community; and
  • assistance with health-related tasks. Health-related tasks, in accordance with state law, include tasks delegated by a registered nurse (RN), health maintenance activities and extension of therapy. An extension of therapy is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow-up to therapy sessions. If appropriate, the member’s attendant can assist the member in accomplishing such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) model, the member, legally authorized representative (LAR) or authorized representative (AR) determines health-related tasks without a nurse assessment, in accordance with state laws; Texas Government Code §531.051(e),  and Title 22 Texas Administrative Code (TAC) §225.4.

CFC-PAS is the same service (i.e., attendant care) as personal care services (PCS). The only difference is the member’s level of care (LOC) and how the service is billed. Information used to build a plan of care (POC) for CFC-PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by the appropriate items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC-PAS if he or she meets CFC LOC criteria.

Members may choose to receive CFC-PAS only if he or she does not need or want CFC habilitation (CFC-HAB).
 

4122 Community First Choice Habilitation

Revision 18-0; Effective September 4, 2018

Community First Choice habilitation (CFC-HAB) assists members with acquisition, maintenance, and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is provided to allow a member to reside successfully in a community setting by assisting the member to acquire, retain and improve self-help, socialization, and daily living skills or assisting with and training the member on ADLs and IADLs. Personal assistance may be a component of CFC-HAB for some members. CFC-HAB services include training, which is interacting face-to-face with a member to train the member in activities, such as:

  • self-care;
  • personal hygiene;
  • household tasks;
  • mobility;
  • money management;
  • community integration, including how to get around in the community;
  • use of adaptive equipment;
  • personal decision-making;
  • reduction of challenging behaviors to allow members to accomplish ADLs, IADLs and health-related tasks; and
  • self-administration of medication.

Information used to build a plan of care (POC) for CFC-HAB may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM) in Section P. Section P of the PCAM should only be administered after the assessor or managed care organization (MCO) service coordinator explains the CFC benefit and the member wishes to be assessed for CFC-HAB.

 

4123 Community First Choice Emergency Response Services

Revision 18-0; Effective September 4, 2018

Community First Choice Emergency Response Services (CFC-ERS) is designed to assist individuals who do not require supervision during the day or are alone for large parts of the day, and are cognitively able to recognize an emergency. This service connects a member to a CFC-ERS provider who notifies local authorities, like paramedics or a fire department, to a member’s emergency. This service is not routinely authorized for members who are minors.

CFC-ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports and are available for members who live alone, who are alone for significant parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use CFC-ERS for CFC-ERS to be authorized.
Need for CFC-ERS is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Z.
 

4124 Community First Choice Support Management

Revision 18-0; Effective September 4, 2018

Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model. Need for support management is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Z.
 

4130 Community First Choice Assessment and Authorization

Revision 18-0; Effective September 4, 2018

 

4131 Assessment for a Nursing Facility Level of Care

Revision 18-0; Effective September 4, 2018

Nursing facility (NF) level of care (LOC) for members seeking Community First Choice (CFC) services is established using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member’s eligibility for NF services according to the Title 40 Texas Administrative Code (TAC) §19.101(88) definition of “medical necessity.”

To ensure TMHP evaluates the submitted SK-SAI for the NF LOC, the MCO must submit the SK-SAI with field Z5a as “Yes” (indicated by a “1”) to indicate that an MN determination is needed. TMHP’s determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines the member does not meet MN, the member is not eligible to receive CFC through the NF LOC. This does not preclude the member or MCO from seeking determination of a different institutional LOC. If TMHP determines the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the NF LOC.
 

4131.1 Reassessment for a Nursing Facility Level of Care

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file for members requiring a reassessment for Community First Choice (CFC) services. The managed care organization (MCO) must indicate “Yes” in Field Z5a (indicated by a "1") to notify Texas Medicaid & Healthcare Partnership (TMHP) that a medical necessity (MN) determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member’s file contains a physician signed Form 2601 for a previous assessment. The MCO must ensure the reassessment is timed to prevent a lapse in service authorization.

4132 Assessment for an Intermediate Care Facility Level of Care

Revision 18-0; Effective September 4, 2018

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member’s named service coordinator and his or her contact information to assist in coordinating assessment activities. Following completion of the determination ID/RC, the LIDDA submits the assessment for a determination of level of care (LOC) to the state. Texas Health and Human Services Commission (HHSC) staff inform both the LIDDA and MCO of the determination. If a member is determined to not meet the LOC provided in an intermediate care facility (ICF), the MCO is responsible for notifying the member through the established denial process.

If a member meets an ICF LOC, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member’s individual service plan (ISP). When the member selects a service provider, the MCO updates the SFTP site noting the member’s selected provider. If a member declines or discontinues Community First Choice (CFC) services, the MCO must update the SFTP site noting the date the member declined or discontinued services.
 

4132.1 Reassessment for an Intermediate Care Facility Level of Care

Revision 18-0; Effective September 4, 2018

Ninety days prior to the expiration of the member’s level of care (LOC) assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility (ICF) LOC. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an Intermediate Care Facility Level of Care, for all reassessments.

If a member continues to meet an ICF LOC, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member’s individual service plan (ISP). When the member selects a service provider, the MCO updates the SFTP site noting the member’s selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.
 

4133 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 18-0; Effective September 4, 2018

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider of mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member’s age. Based on an algorithm, the assessment determines the member’s level of care (LOC). A licensed practitioner must concur with the assessment or may deviate a member to a higher or lower LOC, based on his or her clinical judgement. A licensed practitioner must review the CANS or ANSA at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member’s CANS or ANSA is valid for 12 months.

Members enrolled in the Youth Empowerment Services (YES) waiver meet a psychiatric institutional LOC and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their health plan for functional necessity of CFC services at any time while enrolled in the YES waiver.

 

4133.1 Reassessment for an Institution for Mental Disease Level of Care

Revision 18-0; Effective September 4, 2018

Assessment of a psychiatric institutional level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member’s CFC individual service plan (ISP), the managed care organization (MCO) must refer the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet a psychiatric institutional LOC, the MCO may conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity (MN) for a nursing facility (NF) LOC. If the MCO believes the member will not meet MN and does not have an intellectual or developmental disability, the MCO must notify the member or his or her representative of the denial for CFC services. The member may be eligible for Personal Care Services (PCS), if functionally necessary.

 

4140 Functional Assessment for Community First Choice Services

Revision 18-0; Effective September 4, 2018

Functional need for Community First Choice (CFC) services is primarily established by Sections J, K, L, M, N, O, and P of the STAR Kids Screening and Assessment Instrument (SK-SAI) which collectively form the Personal Care Assessment Module (PCAM). This module contains assessment questions for the personal assistance services (CFC-PAS) and habilitation (CFC-HAB) services available through CFC. The following questions or information in the SK-SAI core module are triggers for the PCAM and may indicate the member has functional need for CFC services:

  • personal care aide is provided in a school or day program;
  • caregiver, member or others are concerned about the member’s developmental status or decline from baseline related to self-care (dressing, bathing, using toilet, self-care);
  • decline in functional status as compared to 90 days ago or since the last assessment;
  • instrumental activity of daily living (IDAL) self-performance;
  • activity of daily living (ADL) self-performance;
  • member is moderately or severely impaired regarding cognitive skills for daily decision making;
  • member requires diet modification to swallow solid food;
  • member requires modifications to swallow liquids;
  • member received Personal Care Services (PCS), attendant care or a home health aide in the last 30 days; and/or
  • member, legally authorized representative (LAR) or authorized representative (AR) requests an assessment for CFC or PCS.

If triggered, the managed care organization (MCO) service coordinator completes the PCAM (Sections J, K, L, M, N, O, and P) to determine attendant care needs. Section P should be completed if the member is specifically seeking CFC services. The MCO service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the MCO service coordinator develops a recommended individual service plan (ISP) for the delivery of CFC services. The MCO service coordinator works with the member, LAR or AR to locate an appropriate provider and sends an authorization to the selected provider.

 

4140.1 Reassessment of Functional Need for Community First Choice

Revision 18-0; Effective September 4, 2018

The need, amount and duration of Community First Choice (CFC) services must be reassessed every 12 months, or when requested due to a change in the member’s health condition or living situation.

4200, Personal Care Services

Revision 18-0; Effective September 4, 2018

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 is available to STAR Kids members from birth through age 20. PCS is considered medically necessary when a member requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member’s disability or chronic health condition. The member’s disability or chronic health condition must be substantiated by a physician statement of need. STAR Kids managed care organizations (MCOs) may not require PCS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typical developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a responsible adult must perform ADLs, IADLs and HMAs on behalf of the member to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member’s physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to assist the individual in performing a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that inhibits the individual’s ability to accomplish ADLs, IADLs or HMAs.
PCS includes:

  • assistance with ADLs and IADLs;
  • nurse-delegated tasks and HMAs within the scope of PCS, as permitted by program policy and Title 22 Texas Administrative Code (TAC) §225; and
  • hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task.

The amount and duration of PCS is determined by the MCO and must take the following into account:

  • Whether the member has a physical, cognitive or behavioral limitation related to a disability or chronic health condition that inhibits the member’s ability to accomplish ADLs or IADLs;
  • The member’s caregiver’s need to sleep, work, attend school and meet his or her own medical needs;
  • The member’s caregiver’s legal obligation to care for, support, and meet the medical, educational and psychosocial needs of other members of the household;
  • The member’s caregiver’s physical ability to perform PCS;
  • Whether requiring the member’s caregiver to perform PCS will put the member’s health or safety in jeopardy;
  • The time periods during which PCS tasks are required by the member, as tasks occur over the course of a 24-hour day and a seven-day week;
  • Whether or not the need to assist the family in performing PCS on behalf of the member is related to a medical, cognitive or behavioral condition that results in a level of functional ability that is below that expected of a typically developing child of the same chronological age; and
  • Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210, Assessment for Personal Care Services.

PCS may be authorized to support a member’s primary caregiver(s) but may not be authorized to supplant a member’s natural support, nor to provide a member’s total care. PCS may be authorized in an individual or group setting including:

  • member’s home;
  • home of the primary or other caregiver;
  • member’s school;
  • member’s day care facility; or
  • community setting in which the member is located.

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, is required to meet the member’s personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation may be submitted to the MCO with documentation of medical necessity (MN).

PCS may not be authorized in a hospital, nursing facility (NF), institution providing psychiatric care, or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).

PCS may not be used as respite, child care, or for the purposes of restraining a member.

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

Members who receive services through the following §1915(c) Medicaid waiver programs receive CFC services through their §1915(c) Medicaid waiver program and are not eligible to receive PCS through the MCO:

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

 

4210 Assessment for Personal Care Services

Revision 18-0; Effective September 4, 2018

Sections J, K, L and M of the STAR Kids Screening and Assessment Instrument (SK-SAI) collectively form the Personal Care Assessment Module (PCAM). This module contains assessment questions for Personal Care Services (PCS). The following questions in the SK-SAI core module are triggers for the PCAM and may indicate the member requires PCS:

  • personal care aide is provided in a school or day program;
  • caregiver, member or others are concerned about the member’s developmental status or decline from baseline related to self-care (dressing, bathing, using toilet self-care);
  • decline in functional status as compared to 90 days ago or since the last assessment;
  • instrumental activity of daily living (IADL) self-performance;
  • activity of daily living (ADL) self-performance;
  • member is moderately or severely impaired regarding cognitive skills for daily decision making;
  • member requires diet modifications to swallow solid food;
  • member requires modifications to swallow liquids;
  • member received PCS, attendant care or a home health aide in the last 30 days; and/or
  • member, legally authorized representative (LAR) or authorized representative (AR) requests an assessment for Community First Choice (CFC) or PCS.

If triggered, the managed care organization (MCO) service coordinator completes the PCAM (Sections J, K, L, M, N and O) to determine attendant care needs. Section P should not be completed if the member is only seeking PCS and not CFC. The MCO service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the MCO service coordinator develops a recommended individual service plan (ISP) for the delivery of PCS. The MCO service coordinator works with the member, LAR or AR to locate an appropriate provider and sends an authorization to the selected provider.

 

4211 Reassessment for Personal Care Services

Revision 18-0; Effective September 4, 2018

The need for and the amount and duration of Personal Care Services (PCS) must be reassessed every 12 months, or when requested due to a change in the member’s health or living condition. The managed care organization (MCO) must obtain a new physician statement of need to substantiate the member’s continued need for PCS upon each annual reassessment.
 

4220 Personal Care Services Providers

Revision 18-0; Effective September 4, 2018

Personal Care Services (PCS) must be provided by an individual who:

  • is 18 years of age or older;
  • is an attendant who:
    • is an employee of a provider organization licensed as a Home and Community Support Services Agency (HCSSA) or organizations licensed to provide home health services or personal assistance services (PAS); or
    • is employed by the member, legally authorized representative (LAR) or authorized representative (AR) through the Consumer Directed Services (CDS) option;
  • has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member, the member’s responsible adult, LAR or AR acting as employer through the CDS option;
  • is not the responsible adult of the member if the member is under the age of 18; and
  • is not the spouse of the member.

4300, Private Duty Nursing

Revision 18-0; Effective September 4, 2018

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 available to STAR Kids members from birth through age 20. PDN services must be available when the services are medically necessary to correct or ameliorate a member’s disability, physical or mental illness, or condition. The services correct or ameliorate when the services improve, maintain or slow the deterioration of the member’s health status.

Nursing services are medically necessary under the following conditions:

  • services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations;
  • services correct or ameliorate the member’s disability, physical or mental illness, or condition; and
  • there is no third-party resource financially responsible for the services.

PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize member health status and outcomes, and to promote family-centered, community-based care as a component of an array of service options.

PDN is considered only when the services are consistent with the definition of “nursing,” as described in the Texas Nursing Practice Act or its implementing regulations. PDN must not be considered for reimbursement if the services are intended solely to provide respite care or child care, or do not directly relate to the member’s nursing needs.

The managed care organization (MCO) may deny or reduce PDN hours if the member’s PDN needs decrease. The MCO may not:

  • deny or reduce PDN when the member’s nursing needs have not decreased;
  • require a member’s responsible adult(s) to provide PDN services to the member;
  • require a member or a member’s responsible adult(s) to designate an alternate caregiver to provide PDN services; or
  • deny or reduce the amount of authorized PDN services because the member’s responsible adult(s) is trained and capable of performing such services, but chooses not to do so.

 

4310 Assessment for Private Duty Nursing

Revision 18-0; Effective September 4, 2018

Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for private duty nursing (PDN). The following questions/information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires PDN:

  • skilled nursing visit or PDN is provided in a school or day program;
  • member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing facility (NF) stay in the past year;
  • member requires enteral or parenteral feeding;
  • member received any of the following treatments in the last 30 days:
    • chemotherapy;
    • dialysis;
    • intravenous (IV) medication;
    • oxygen therapy;
    • radiation;
    • suctioning;
    • tracheotomy care;
    • transfusion;
    • ventilator;
    • wound care;
    • nebulizer;
    • urinary catheter care insertion or maintenance;
    • comatose or persistent vegetative state managed care;
    • continuous positive airway pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP);
    • chest percussive therapy;
    • active medication adjustment;
    • intermittent positive pressure breathing (IPPB); and/or
    • seizure management; or
  • member is being assessed for Community First Choice (CFC) services or the Medically Dependent Children Program (MDCP).

If triggered, the MCO service coordinator completes the NCAM addendum (Section Q) to determine the member’s nursing needs. The MCO service coordinator also completes SK-SAI Section Y to assist in developing a recommended number of hours. Based on the assessment, the MCO service coordinator develops a recommended individual service plan (ISP) for the delivery of PDN. The MCO service coordinator works with the member, legally authorized representative (LAR) or authorized representative (AR) to locate an appropriate provider and send an authorization to the selected provider.

 

4311 Reassessment and Reauthorization

Revision 18-0; Effective September 4, 2018

At a minimum, the need for and the amount and duration of private duty nursing (PDN) must be reassessed 90 days following the initial authorization and every six months thereafter, or when requested due to a change in the member’s health or living condition. A physician order must be renewed with any reassessment.

 

4320 Providers of Private Duty Nursing

Revision 18-0; Effective September 4, 2018

Private duty nursing (PDN) may be provided by a licensed Home and Community Support Services Agency (HCSSA), an independently enrolled registered nurse (RN) or a licensed vocational nurse (LVN) under the supervision of an RN, contracted with the STAR Kids managed care organization (MCO).

An RN must develop a plan of care (POC) that accounts for the following items, at a minimum:

  • clinical summary that documents active diagnoses and current clinical condition;
  • member’s mental or cognitive status;
  • types of treatments and services, including amount, duration and frequency;
  • description of any required equipment and/or supplies;
  • member’s prognosis;
  • member’s rehabilitation potential;
  • member’s current functional limitations;
  • activities permitted;
  • member’s nutritional requirements;
  • member’s medications, including dose, route and frequency;
  • safety measures to protect against injury;
  • instructions for timely discharge or referral;
  • date the member was last seen by the treating physician;
  • identification of activities of daily living (ADL) and health maintenance activities with which the member needs assistance. The POC must indicate whether the tasks must be performed by a licensed nurse or a qualified aide, or may be performed by a personal care attendant;
  • certification statement that an identified contingency plan exists; and
  • all other medical orders.

Adults legally responsible for the member cannot be the paid PDN provider if the member is under age 18 or the spouse of the member.

 

4330 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018

Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400, Prescribed Pediatric Extended Care Centers, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service area (SA). A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual’s medical condition or the authorized hours are not commensurate with the individual’s medical needs. Per Title 1 Texas Administrative Code (TAC) §363.209(c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. Texas Medicaid & Healthcare Partnership’s (TMHP’s) fee-for-service (FSS) Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual’s medical needs. The PDN provider would be notified by the managed care organization (MCO) of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity (MN) for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care (POC) for the individual. The MCO service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.

4400, Prescribed Pediatric Extended Care Centers

Revision 18-0; Effective September 4, 2018

Prescribed Pediatric Extended Care Center (PPECC) services may be a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP) for STAR Kids members who meet the following medical necessity (MN) criteria for admission:

  • eligible for THSteps-CCP;
  • age 20 years or younger;
  • has an acute or chronic condition that requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
  • considered to be a medically dependent or technologically dependent member;
  • stable for outpatient medical services, and does not present a significant risk to other individuals or personnel at the PPECC;
  • requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:
    • deterioration of a chronic condition;
    • loss of function;
    • imminent risk to health status due to medical fragility; or
    • risk of death;
  • has a prescription for PPECC services signed and dated by an ordering physician who has personally examined the member within 30 days prior to admission and reviewed all appropriate medical records;
  • has consent for the member’s admission to the PPECC signed and dated by the member or responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of PDN by the member or responsible adult in both managed care and non-managed care service delivery systems; and
  • resides with the responsible adult and does not reside in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility (NF), intermediate care facility (ICF) or special care facility.

PPECC services require prior authorization and are intended as an alternative to private duty nursing (PDN). However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, personal care services (PCS), Home Health Skilled Nursing (HHSN), Home Health Aide (HHA), and therapies (physical therapy (PT), occupational therapy (OT), speech therapy (ST)), as well as respiratory therapy and Early Childhood Intervention (ECI) services rendered in the member’s residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but PPECC services must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

  • The development, implementation and monitoring of a comprehensive plan of care (POC) that:
    • is provided to a medically dependent or technologically dependent member;
    • is developed in conjunction with the member’s caregiver(s), ordering physician and interdisciplinary team;
    • specifies the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional and developmental needs of the member and the training needs of the member’s caregiver(s);
    • specifies if transportation to and from the PPECC is needed; and
    • is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
  • Direct skilled nursing care and caregiver training and education intended to:
    • optimize the member’s health status and outcomes; and
    • promote and support family-centered, community-based care as a component of an array of service options by:
      • preventing prolonged or frequent hospitalizations or institutionalization;
      • providing cost-effective, quality care in the most appropriate environment; and
      • providing training and education of caregivers.
  • Nutritional counseling and dietary services as specified in a member’s POC.
  • Assistance with activities of daily living (ADL) while the member is in the PPECC.
  • Psychosocial and functional development services.
  • Transportation services to and from a PPECC. Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC. When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle. The member must be able to utilize transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance. Transportation is billed separately by the PPECC when utilized by a member. A non-emergency ambulance may not be utilized for transport to and from a PPECC.

Note: A member or responsible adult may decline a PPECC’s transportation and choose to be transported by other means, including his or her responsible adult. A member’s legally authorized representative (LAR) or authorized representative (AR) is not required to accompany a member when the member receives services in a PPECC, including transportation services to and from the center and therapy services that are billed separately. Fee-for-service (FSS) Medicaid does not require prior authorization for the transportation billing code. Rather, authorization for PPECC services implies authorization for transportation.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

  • baby food or formula;
  • services to members that are related to the PPECC owner by blood, marriage or adoption; and
  • services covered separately by Texas Medicaid, such as therapies or durable medical equipment (DME), or individualized comprehensive case management beyond that required for service coordination.

 

4410 Assessment for Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018

Section Q from the Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

  • current authorization for private duty nursing (PDN);
  • skilled nursing visit or PDN is provided in a school or day program;
  • member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing facility (NF) stay in the past year;
  • member requires enteral or parenteral feeding;
  • member received any of the following treatments in the last 30 days:
    • chemotherapy;
    • dialysis;
    • intravenous (IV) medication;
    • oxygen therapy;
    • radiation;
    • suctioning;
    • tracheotomy care;
    • transfusion;
    • ventilator;
    • wound care;
    • nebulizer;
    • urinary catheter care – insertion or maintenance;
    • comatose or persistent vegetative state – manage care;
    • continuous positive airway pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP);
    • chest percussive therapy;
    • active medication adjustment;
    • intermittent positive pressure breathing (IPPB); and/or
    • seizure management; and
  • member is being assessed for Community First Choice services (CFC) or the Medically Dependent Children Program (MDCP).

If triggered, the managed care organization (MCO) service coordinator completes the NCAM addendum (Section Q) to determine the member’s nursing needs. The MCO service coordinator also completes SK-SAI Section Y to assist in developing a recommended number of service hours. Based on the SK-SAI, the MCO service coordinator develops a recommended individual service plan (ISP) for the services of a PPECC. The MCO service coordinator works with the member, legally authorized representative (LAR) or authorized representative (AR) to locate an appropriate provider and sends an authorization to the selected provider.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.

 

4411 Reassessment and Reauthorization of Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018

At a minimum, the need for and the amount and duration of services from a Prescribed Pediatric Extended Care Center (PPECC) must be reassessed 90 days following initial authorization and every 180 days following, or when requested due to a change in the member’s health or living condition. A physician order must be renewed with any reassessment.

 

4420 Providers of Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with Title 40 Texas Administrative Code (TAC) §15, and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions and in-state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24 hour period. Services may not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual (TMPPM) and PPECC medical policy. These components include:

  • member’s name, date of birth (DOB) and Medicaid identification (ID) number;
  • PPECC’s name, Texas Provider Identifier (TPI), National Provider Identifier (NPI) and hours of operation, as well as address, telephone number and fax number;
  • ordering physician’s name, telephone number, TPI and NPI;
  • date the PPECC nursing assessment was completed and name, title and credentials of the registered nurse (RN) who completed the POC and his or her dated signature;
  • name, title and credentials of the team member who completed the POC and his or her dated signature;
  • date the member was last seen by the ordering physician;
  • requested start of care (SOC) date for PPECC services;
  • all pertinent diagnoses and known allergies;
  • nursing services to be provided, including amount, duration and frequency;
  • member’s prognosis;
  • member’s mental status;
  • rehabilitation potential;
  • equipment and/or supplies required;
  • therapies (occupational, physical, speech, and/or respiratory care), including how those therapies are accessed, amount, duration and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented;
  • other prescribed services, including amount, duration and frequency;
  • nutritional requirements, including type, method of administration and frequency;
  • medications, including the dose, route, frequency and any medication-related allergies, if known;
  • treatments, including amount and frequency;
  • wound care orders and measurements;
  • safety measures to protect against injury;
  • functional developmental services and psychosocial services, including amount, duration and frequency;
  • name, telephone number and signature of the responsible adult;
  • member’s emergency contact name and telephone number;
  • confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm or electrical malfunctions), and for emergencies that occur while the member is in the care of the PPECC;
  • list of services the member receives in the home and school settings (e.g., Early Childhood Intervention (ECI), therapies, School Related Health Services (SHARS), Personal Care Services (PCS), private duty nursing (PDN), therapies, skilled home health, case management services, hospice, and §1915(c) Medicaid waiver programs such as Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL) and Community Living Assistance and Support Services (CLASS)). Note: Services provided under these programs will not prevent a member from obtaining medically necessary services;
  • member-specific measureable goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider;
  • responsible adult training needs;
  • prior and current functional or medical limitations;
  • permitted activities;
  • member’s scheduled days and hours of attendance;
  • confirmation of a discharge plan, including instructions for timely discharge or referral;
  • method of transportation;
  • PDN provider name, TPI, NPI, address, telephone and fax number, if known;
  • ordering physician signature and date of signature;
  • transportation services needed by a member to access PPECC service (a non-emergency ambulance may not be used for transport to and from a PPECC); and
  • services outlined in the Title 1 Texas Administrative Code (TAC) §363.211.

A face-to-face evaluation must be performed annually by the ordering physician. A physician order is required for each initial and recertification authorization, and revisions. A physician in a relationship with a PPECC (employed by or contracted with a PPECC) cannot provide the physician’s order, unless the physician is the member’s treating physician and has examined the member outside of the PPECC setting. The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

  • speech, physical, and occupational therapies (including therapies rendered by a home health agency);
  • certified respiratory care services; and
  • early intervention services provided through the ECI program, which are subject to ECI policies.

Authorization Requirements

Per Title 1 Texas Administrative Code (TAC) §363.211, initial, recertification and revision requests for PPECC services must include the following documentation, which adheres to requirements in the TMPPM:

  1. physician order for services (a physician signature on the PPECC POC serves as a physician order for authorization purposes);
  2. a POC developed by the PPECC;
  3. all required prior authorization forms listed in the TMPPM, or MCO forms if the forms contain comparable content; and
  4. signed consent of the participant or participant’s responsible adult documenting the choice of PPECC services. The signed consent must include an acknowledgement by the participant or the participant’s responsible adult that he or she has been informed that other services such as PDN might be reduced as a result of accepting PPECC services. Consent to share the participant’s protected health information (PHI) with the participant’s other providers, as needed to ensure coordination of care, must also be obtained.

Forms available online for PPECC include:

  • CCP Prior Authorization Request (requires ordering physician signature).
  • PPECC POC (requires ordering physician, PPECC RN and member or responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the TMPPM.
  • Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers (requires ordering physician, PPECC RN, and member/responsible adult signatures). This form contains required individual and physician acknowledgements and consent.

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service (FSS) forms, and are subject to approval by HHSC.

 

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 18-0; Effective September 4, 2018

Refer to Section 4330, Private Duty Nursing and Prescribed Pediatric Extended Care Center Services, for details on coordination of services between private duty nursing (PDN) and Prescribed Pediatric Extended Care Center (PPECC). Both PDN and PPECC are ongoing skilled nursing services, and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC, or a combination of both services.

4500, Day Activity and Health Services

Revision 18-0; Effective September 4, 2018

Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations (MCOs) may not require DAHS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for DAHS.

 

4510 Assessment for Day Activity and Health Services

Revision 18-0; Effective September 4, 2018

The potential for therapeutic benefit must be established by a physician’s assessment and requires a physician’s order.

A Day Activity and Health Services (DAHS) facility nurse must complete a health assessment for each STAR Kids member at the facility. The assessment may be conducted by a registered nurse (RN) or licensed vocational nurse (LVN), based upon the member’s condition at the time of initial assessment. The DAHS facility nurse completes a health assessment at either the facility or the member’s home. Health assessments must be conducted, at minimum, when:

  • members need initial assessment for prior authorization by a STAR Kids managed care organization (MCO);
  • members transfer to a new facility (conducted by the new facility);
  • at reauthorization; and
  • the DAHS nurse determines a member needs to be reassessed.

The member, legally authorized representative (LAR) or authorized representative (AR) must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member’s functioning.

 

4511 Reassessment for Day Activity and Health Services

Revision 18-0; Effective September 4, 2018

Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment may be no older than 90 days from the date at which an authorization is requested.

A member is reassessed at regular intervals by the facility nurse. In addition, the facility nurse assesses the member for nursing, physical rehabilitation and nutritional services when a member:

  • first enters the facility;
  • transfers from another Day Activity and Health Services (DAHS) facility; and
  • experiences a condition change. If the change in condition necessitates, the facility nurse coordinates with the member’s managed care organization (MCO) service coordinator or physician for a physician assessment.

 

4520 Day Activity and Health Services Providers

Revision 18-0; Effective September 4, 2018

To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission (HHSC) and comply with Title 40 Texas Administrative Code (TAC) §98, Adult Day Care and Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

  • Nursing services, which include a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of Personal Care Services (PCS).
  • Physical rehabilitative services, which include restorative nursing and group/individual exercises with range of motion exercises.
  • Nutrition services, which include:
    • one hot noon meal a day;
    • a mid-morning and mid-afternoon snack;
    • preparation of foods required for special diets; and
    • dietary counseling and nutrition education for the individual and his or her family.
  • Transportation, including to and from the facility, as well as to and from the facility on an activity outing, and to and from a facility approved to provide therapies if the member requires specialized services on days of attendance at the DAHS facility. The provider must:
    • coordinate the use of other transportation resources within the community;
    • make every effort to have families transport individuals;
    • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by the facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety (DPS); and
    • have sufficient staff to ensure the safety of members being transported to and from their homes.
  • Activities and other supportive services:
    • Activities offered at the facility must be meaningful, fun, therapeutic and educational;
    • A provider must offer at least three different scheduled activities in at least one or more of the following activities:
      • Exercise;
      • Games;
      • Educational or reality orientation; and/or
      • Crafts; and
    • A provider must offer at least one of the following activities, at cost to the provider, monthly:
      • Trips or special events; or
      • Cultural enrichment.

4600, Medically Dependent Children Program Services

Revision 18-0; Effective September 4, 2018

The Medically Dependent Children Program (MDCP) provides respite, Flexible Family Support Services (FFSS), minor home modifications, adaptive aids, Transition Assistance Services (TAS), supported employment (SE), and employment assistance (EA). These services are for eligible members to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility (NF) residents under 21 years of age.

Only applicants and members who are released from the MDCP interest list and assessed as meeting medical necessity (MN) are eligible for MDCP services. Federal guidelines require that members must need and use one or more MDCP service to qualify and maintain eligibility for MDCP. All members must have an unmet need for and use for at least one MDCP service per individual service plan (ISP) year to qualify for MDCP.

The managed care organization (MCO) service coordinator must inform all members receiving MDCP services that, at a minimum, one MDCP service must be used per ISP year to qualify and maintain enrollment in MDCP.

Upon initial assessment for MDCP or at an MDCP member’s reassessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the MCO service coordinator will discuss the applicant’s or member’s needs in relation to the available MDCP services. The MCO service coordinator will develop a recommended ISP if the member’s Resource Utilization Group (RUG) is not known. The RUG determines the member’s budget.

Example: The MCO service coordinator could ask the applicant, member, legally authorized representative (LAR) or authorized representative (AR) if he or she would like respite or have a desire for employment services. The MCO service coordinator could ask if the applicant or member requires adaptive aids, minor home modifications, or could benefit from FFSS. The MCO service coordinator could inquire which services the member, LAR or AR would like more of, should the member’s budget be unknown during the assessment. Based on the discussion, the MCO service coordinator will develop a recommended ISP for that member and work with the member, LAR or AR in person or telephonically to develop a final ISP once the member’s budget is known.

4700, Medically Dependent Children Program Respite and Flexible Family Support Services

4710 Medically Dependent Children Program Respite

Revision 18-0; Effective September 4, 2018

Respite is a service that provides temporary relief from caregiving to the applicant, member or his or her primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the member’s parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for respite services.

In-home respite may be delivered by a Home and Community Support Services Agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. Respite may be delivered by attendants or nurses employed through the CDS option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member’s relative. Out-of-home respite may be provided in a facility setting, such as a nursing facility (NF) or hospital, or in a camp setting.

Respite is intended to provide relief to the primary caregiver. It may only be provided when a member’s primary caregiver would normally provide the member’s care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or private duty nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite is a service to provide relief to the primary caregiver, if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member’s home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks he would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that scenario, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

STAR Kids MCOs may determine the number of units of respite to authorize for an MDCP member, based on the member’s, legally authorized representative’s (LAR’s) or authorized representative’s (AR’s) preferences and the member’s approved cost limit. MCOs must develop internal processes related to respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to “bank” respite hours to use at a later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP.

 

4711 In-Home Respite

Revision 18-0; Effective September 4, 2018

In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member, legally authorized representative (LAR) or authorized representative (AR) under the Consumer Directed Services (CDS) option.

A member’s in-home respite is limited by the amount of the member’s cost limit. If the member chooses the CDS option, the member is limited by his or her available budget. Managed care organizations (MCOs) may have additional policies and procedures regarding reserving capacity in a member’s budget. The provision of in-home respite is documented on the individual service plan (ISP).

 

4711.1 Attendant with Delegated Tasks

Revision 18-0; Effective September 4, 2018

A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician’s supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his or her supervision, per BON rules. A practitioner or RN may delegate skilled tasks to an attendant required to meet a member’s needs.

If the member does not have a skilled task need during the delivery of respite, he or she does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the managed care organization (MCO) service coordinator or the Home and Community Support Services Agency (HCSSA) provider determines the use of this provider type places the individual’s health and welfare at risk, the MCO service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member’s physician.

If a member, legally authorized representative (LAR) or authorized representative (AR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member, LAR or AR is directing the member’s services, he or she must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

4712 Out-of-Home Respite

Revision 18-0; Effective September 4, 2018

Respite may be provided out of the home if indicated in a physician’s order or if the member, legally authorized representative (LAR) or authorized representative (AR) prefer. Out-of-home respite providers are:

  • special care facilities licensed by the Texas Department of State Health Services (DSHS);
  • day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
  • hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
  • nursing facilities (NFs) licensed by the Texas Health and Human Services Commission (HHSC);
  • camps licensed by DSHS and accredited by the American Camping Association; and
  • foster families approved by a DFPS child placing agency.

Facility-based respite is limited to 29 days per the individual service plan (ISP) period. The 29-day limit applies to the total number of days a member receives respite in a hospital or NF.

 

4720 Respite Limits

Revision 18-0; Effective September 4, 2018

Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.

Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member’s admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.

The member may request to exceed the 29 day facility-based respite limit. Within five days of the request to exceed the 29 day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:

  • primary caregiver;
  • member’s spouse; or
  • member’s parent, legally authorized representative (LAR), authorized representative (AR), guardian or managing conservator, if the individual is under age 18.

 

4730 Flexible Family Support Services

Revision 18-0; Effective September 4, 2018

Flexible Family Support Services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:

  • child care;
  • independent living; and
  • post-secondary education.

FFSS include personal care supports for basic activities of daily living (ADL) and instrumental activities of daily living (IADL), skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. FFSS may be delivered by the Home and Community Support Services Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services (CDS) option. FFSS are documented on the individual service plan (ISP). STAR Kids managed care organizations (MCOs) may not require FFSS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for FFSS.

 

4731 Flexible Family Support Services in Child Care

Revision 18-0; Effective September 4, 2018

The member’s parent or guardian is responsible for basic child care either in or out of the member’s home. Flexible Family Support Services (FFSS) support the member’s participation in child care when the service provided by the child care does not support the member’s disability-related needs. If the member’s child care is not able to meet the member’s activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs, the managed care organization (MCO) service coordinator may authorize FFSS.

To determine the need for FFSS for participation in child care, the MCO service coordinator must discuss the parent’s or guardian’s plan for obtaining basic child care and whether it will be provided in or out of the member’s home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.

The caregiver’s cost for child care does not impact the member’s need for FFSS. The MCO service coordinator must determine the amount of hours needed to support the member’s needs within the Medically Dependent Children Program (MDCP) individual service plan (ISP) cost limit. The MCO service coordinator should ask the caregiver about the member’s personal and skilled task needs and the time needed to address those needs. The MCO service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member’s health and welfare.

FFSS does not replace Personal Care Services (PCS) provided through Texas Health Steps (THSteps) or Community First Choice (CFC). FFSS are provided when a member regularly participates in child care in the home or out of the home, or participates in a community program or educational service.

 

4732 Flexible Family Support Services for Independent Living

Revision 18-0; Effective September 4, 2018

A member may indicate a desire for increased independence as he or she matures. If the member needs assistance with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task, the managed care organization (MCO) service coordinator may authorize Flexible Family Support Services (FFSS) to help the member with his or her goal for independent living.

Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program (MDCP) service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills he or she will need to live independently as adults.

To determine the need for FFSS for independent living, the MCO service coordinator must discuss the member’s and primary caregiver’s plan for the member’s independent living. When identifying the member’s need for this service, the MCO service coordinator should address age appropriateness for the tasks required to meet these needs. The MCO service coordinator must determine the amount of FFSS needed to support the member’s needs. The MCO service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member’s age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.

 

4733 Flexible Family Support Services in Post-Secondary Education

Revision 18-0; Effective September 4, 2018

A member can access Flexible Family Support Services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the managed care organization (MCO) service coordinator may authorize FFSS so the member may participate in post-secondary education.

A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member’s personal, skilled and delegated skilled task needs.

To determine the need for FFSS in post-secondary education, the MCO service coordinator must identify the member’s need for assistance and the amount of FFSS needed to support the member’s needs. The MCO service coordinator should identify the member’s personal and skilled task needs and the amount of time needed to address those needs. The MCO service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member’s health and welfare.

 

4734 Flexible Family Support Services Requiring Delegated Tasks

Revision 18-0; Effective September 4, 2018

A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician’s supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his or her supervision, per BON rules. A practitioner or RN may delegate skilled tasks to an attendant required to meet a member’s needs.

If the member does not have a skilled task need during the delivery of Flexible Family Support Services (FFSS), he or she does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the managed care organization (MCO) service coordinator or the Home and Community Support Services Agency (HCSSA) provider determines the use of this provider type places the individual’s health and welfare at risk, the MCO service coordinator should not authorize an attendant with delegated tasks to deliver FFSS, unless determined appropriate by the member’s physician.

If a member, legally authorized representative (LAR) or authorized representative (AR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member, LAR or AR is directing the member’s services, he or she must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

4740 Flexible Family Support Services Limits

Revision 18-0; Effective September 4, 2018

Flexible Family Support Services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the managed care organization (MCO) service coordinator may not authorize FFSS during the same time period the individual receives Personal Care Services (PCS) or Community First Choice (CFC) services.

Title 42 Code of Federal Regulations (CFR) §441.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including FFSS, not be provided to a member who is admitted to a hospital, a resident of a nursing facility (NF) or a resident of an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID).

The MCO service coordinator may not authorize FFSS during the member’s school hours in primary or secondary educational settings.

4800, Adaptive Aids, Minor Home Modifications and Transition Assistance Services

4810 Adaptive Aids

Revision 18-0; Effective September 4, 2018

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 he or she live.

A member must exhaust any applicable Medicare, Medicaid or other third-party resources (TPR) for durable medical equipment (DME) and adaptive aids before adaptive aids available under the Medically Dependent Children Program (MDCP) are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.

 

4811 Service Limits on Adaptive Aids

Revision 18-0; Effective September 4, 2018

The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the managed care organization (MCO) member case file. After any applicable state plan benefits (e.g., durable medical equipment (DME)) are exhausted, adaptive aids covered in the Medically Dependent Children Program (MDCP) include:

  • 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.

The MCO may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member’s annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member’s agreement to pay these costs in the MCO member case file. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member’s signature, the date of the member’s agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.

 

4820 Minor Home Modifications

Revision 18-0; Effective September 4, 2018

A minor home modification 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 his or her home. If a home modification is requested and the member, legally authorized representative (LAR) or authorized representative (AR) does not own the home in which the modification will take place, the member, LAR, AR or the managed care organization (MCO) service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids MCOs may not require minor home modification providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for minor home modifications services.

 

4821 Service Limits on Minor Home Modifications

Revision 18-0; Effective September 4, 2018

The minor home modification lifetime limit is $7,500. The managed care organization (MCO) service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with Medically Dependent Children Program (MDCP) funds. The MCO service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the MCO member case file. A minor home modification must not create a new structure or add square footage to the home.

The MCO may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member’s lifetime limit for minor home modifications.

Minor home modifications are limited to:

  • purchase and installation of permanent and portable ramps not covered by other sources;
  • widening of doorways;
  • modification of bathroom facilities; and
  • modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

Minor home modifications must:

  • adhere to Americans with Disabilities Act (ADA) requirements;
  • meet Texas Accessibility Standards;
  • meet all applicable state and/or local building codes; and
  • have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider’s warranty, the MCO service coordinator may authorize up to $300 for the member, legally authorized representative (LAR) or authorized representative (AR) to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member’s agreement to pay these costs in the MCO member case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member’s signature, the date of the member’s agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.

 

4830 Transition Assistance Services

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) service coordinator must advise applicants or members who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the applicant or member needs assistance in setting up a household when relocating into the community from the NF. STAR Kids MCOs may not require TAS providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for TAS. The applicant or member may access TAS if he or she:

  • plan to rent an apartment;
  • plan to rent a house;
  • have a home, but the utilities have been off while in the NF;
  • have a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
  • need belongings moved from the NF to the new residence.

TAS may be available to pay for non-recurring set-up expenses for applicants or members transitioning from NFs into MDCP and to individuals temporarily suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the applicant’s or member’s transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

  • security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
  • essential furnishings for the apartment or house;
  • moving expenses required to move into the house or apartment; and
  • site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

The applicant or member selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the applicant, member, legally authorized representative (LAR) or authorized representative (AR) to attest that the items requested for TAS are the basic, essential needs required to move into the community, and he or she agree the TAS agency selected is authorized to make the purchases for them. The MCO service coordinator must explain to the applicant or member that the service will not be authorized until the applicant or member is determined eligible for MDCP services, and notified in writing that he or she is eligible. The MCO service coordinator must contact the applicant, member, LAR or AR before certification to verify the applicant or member has made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member receives must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.

 

4831 Deposits

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant’s or member’s name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months’ rent. The MCO service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the applicant’s or member’s service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the applicant’s or member’s name, or to pay for arrears on previous utilities if the account is in the applicant’s or member’s name and he or she will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The MCO may have internal policies regarding the type of telephone that may be authorized.

TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the applicant’s or member’s transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the applicant’s or member’s place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or member identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the applicant or member not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.

 

4832 Moving Expenses

Revision 18-0; Effective September 4, 2018

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the applicant’s or member’s belongings from the nursing facility (NF) to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or member from the NF to his or her residence in the community.

 

4833 Site Preparation

Revision 18-0; Effective September 4, 2018

Transition Assistance Services (TAS) can be used to pay for preparing the applicant’s or member’s place of residence for occupancy if the current condition of the residence prevents the applicant’s or member’s transition from the nursing facility (NF). Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and is in need of some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the applicant or member is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the applicant’s or member’s residence has been unattended or the applicant or member is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.

 

4834 Limits on Transition Assistance Services

Revision 18-0; Effective September 4, 2018

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per applicant or member. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the managed care organization (MCO) member case file. The MCO service coordinator must be as specific as possible when describing the items purchased. A nursing facility (NF) resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to NF placement may receive a one-time TAS authorization if the MCO service coordinator determines that no other resources are available to pay for the basic services or items needed by the applicant or member. TAS may not be used for:

  • monthly rent or mortgage expenses;
  • current or future use of utilities;
  • service upgrades;
  • food items; or
  • any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable television (TV), satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to applicants or members who are discharged from an NF and require TAS to set up a household.

 

4835 Transition Assistance Services Agency Responsibilities

Revision 18-0; Effective September 4, 2018

The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the authorization carefully and contact the MCO if there are any questions regarding the authorization. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member, legally authorized representative (LAR) or authorized representative (AR), if necessary, to discuss the item in question. The MCO provides a revised TAS authorization within two business days if it clarifies an item is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member, legally authorized representative (LAR) or authorized representative (AR), if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member, LAR or AR by the completion date to confirm that all authorized TAS services were delivered.

 

4836 Three-Day Monitor Requirement

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. If the member reports any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the MCO member case record.

 

4837 Failure to Leave the Nursing Facility

Revision 18-0; Effective September 4, 2018

While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the nursing facility (NF), there may be situations in which the member changes his mind or has a change in health making it impossible for him to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave an NF does not count against a member’s lifetime TAS limit.

  • If the TAS agency is unsuccessful in returning the item(s) for the amount of monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to the cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting the individual to establish a home.
  • If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
  • If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the cost of the service, not to exceed the authorized amount.

If the member is only in the community for a few days and returns to the NF, the member keeps the item(s) purchased through TAS.

4900, Supported Employment and Employment Assistance

Revision 18-0; Effective September 4, 2018

Senate Bill 45, 83rd Legislature, Regular Session, 2013, required all §1915(c) Medicaid waiver programs offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program (MDCP) are EA and SE. STAR Kids managed care organizations (MCOs) may not require EA or SE providers to obtain a denial or explanation of benefits from a member’s primary insurance before seeking reimbursement for EA or SE services.

 

4910 Employment Assistance

Revision 18-0; Effective September 4, 2018

Employment assistance (EA) is provided to a member receiving Medically Dependent Children Program (MDCP) services to help the individual locate paid employment in the community and includes:

  • 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.

For an MDCP member, the managed care organization (MCO) service coordinator must ensure and document that employment services are not available to the member from the member’s school district or other available community resource before authorizing MDCP EA services.

The MCO service coordinator refers the member to the Texas Workforce Commission (TWC) within 30 days of meeting with a member and identifying an interest in obtaining employment. The MCO service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at http://www.twc.state.tx.us/directory-workforce-solutions-offices-services-0#workforceServices.

A member who has been referred for TWC or contacted TWC himself or herself is not eligible to receive EA through MDCP until TWC has developed the Individualized Plan of Employment (IPE) and the member has signed the IPE or the member is denied services through TWC. If a member refuses to contact TWC, he or she may not receive MDCP-funded EA. If a member is denied assistance through TWC, EA through MDCP may be authorized.

If the member has exhausted TWC services or been determined ineligible for TWC services, the MCO service coordinator authorizes a minimum of 10 hours for employment on the member’s individual service plan (ISP). EA can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member’s MDCP budget.

 

4911 Coordination with Texas Workforce Commission for Employment Assistance

Revision 18-0; Effective September 4, 2018

Upon request and with proper authorization for disclosure, the managed care organization (MCO) service coordinator will assist the member to provide the Texas Workforce Commission (TWC) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

  • photo identification;
  • original Social Security card;
  • member’s home address and mailing address;
  • names and addresses of any physicians the member has seen recently;
  • names and addresses of any schools the member has attended;
  • information about the member’s medical insurance;
  • list of places the member has worked, including type of job, dates, the reason for leaving and salary;
  • proof of income for the member and his or her spouse, or parents (if the parents claim the member as a dependent on their income tax);
  • proof of expenses related to monthly mortgage or rental payments, debts imposed by court order, personal medical costs and other disability-related expenses;
  • names, addresses and telephone numbers of two people who will always know how to contact the member;
  • any reports of recent medical exams, school records or other information that may help the VRC understand the member’s disability;
  • member’s most recent individual service plan (ISP);
  • any current vocational assessments or person-directed plans that focus on employment opportunities;
  • any other available records pertaining to the member’s disabilities, including but not limited to medical, psychological and psychiatric reports;
  • copy of the member’s court-ordered guardianship documents, if any guardian has been appointed; and
  • contact information for the member’s MCO service coordinator.

If the VRC determines TWC is not the appropriate resource to meet the member’s needs and does not take an application for services, documentation of this decision in the member’s record serves as sufficient evidence that TWC is not available and the member is eligible to receive Medically Dependent Children Program (MDCP)-funded employment assistance (EA).

TWC will:

  • notify a member in writing if the member is determined to be eligible, ineligible or if TWC is unavailable;
  • notify a member in writing when TWC is completed;
  • develop with the eligible member an Individualized Plan for Employment (IPE) within 90 days of determination of eligibility for services;
  • after the IPE is completed, begin coordinating the provision of services as identified on the IPE; and
  • upon request and with proper authorization for disclosure, provide copies of any of the member’s records to the MCO service coordinator, including the following documents:
    • completed copy of the member’s application statement;
    • completed IPE;
    • written documentation specifying a member’s eligibility status; and
    • notification letter indicating TWC is completed.

If TWC has not notified the member of an eligibility decision within 60 days of the initial TWC appointment, the member’s MCO service coordinator will attempt to contact the assigned TWC VRC to determine the status of the application and document the contact in the narrative notes.

The member’s MCO service coordinator will ensure that communication is maintained with the assigned TWC VRC regarding MDCP-funded services provided between the Vocational Rehabilitation (VR) referral and the “start date” of TWC, as defined in the individual’s TWC VR IPE.

At the request of a member determined eligible for TWC, the MCO service coordinator, if possible, will assist the member and:

  • participate in TWC planning meetings related to the member’s employment, or ensure other individuals important to the member attend, as appropriate;
  • take an active role in providing input to the TWC IPE, or ensure other individuals important to the member provide input, as appropriate; and
  • review the long term services and supports (LTSS) listed on the TWC IPE and if any of those services and supports are available through the MDCP, incorporate them in a revision to the member’s ISP prior to the end of TWC services.

The member’s provider must begin providing or subcontracting for those services and supports approved in the member’s ISP without a gap between the provision of TWC and MDCP services.

 

4912 Employment Assistance Providers

Revision 18-0; Effective September 4, 2018

Employment assistance (EA) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member, legally authorized representative (LAR) or authorized representative (AR) under the Consumer Directed Services (CDS) option. At a minimum, the EA provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the individual, and satisfy one of these options:

Option 1:

  • Bachelor’s degree in rehabilitation, business, marketing or a related human services field; and
  • six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

  • Associate’s degree in rehabilitation, business, marketing or a related human services field; and
  • one year of paid or unpaid experience providing services to people with disabilities.

Option 3:

  • High school diploma or Certificate of High School Equivalency (General Education Development (GED) credentials); and
  • two years of paid or unpaid experience providing services to people with disabilities.

Under the CDS option, the provider cannot be the member’s legal guardian or the spouse of the legal guardian.

 

4920 Supported Employment

Revision 18-0; Effective September 4, 2018

Supported employment (SE) services provide assistance to help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.

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.

Competitive employment is work:

  • in the competitive labor market in which anyone may compete for employment that is performed on a full-time or part-time basis in an integrated setting; and
  • for which a member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

An integrated setting is a setting typically found in the community in which members interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

  • groups of people with disabilities work in an area that is not part of the general workplace where people without disabilities work; or
  • a mobile crew of people with disabilities work in the community.

An MDCP member may seek SE to provide assistance to the member in maintaining self-employment. Self-employment is work in which the member:

  • solely owns, manages and operates a business;
  • is not an employee of another person, entity or business; and
  • actively markets a service or product to potential customers.

SE may only be authorized through MDCP if documentation is maintained in the member’s record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (Title 20 United States Code (U.S.C.) §1401 et seq.) or the Texas Workforce Commission (TWC).

 

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third-party resources (TPR) before using Medically Dependent Children Program (MDCP) employment services.

Activities include:

  • devoting time during a member’s initial individual service plan (ISP) meeting to discuss employment with the member and family and the process to obtain employment services and supports;
  • making a referral to TWC, assisting with completing the application form, and documenting the referral and outcome of the referral in the member’s case record;
  • continuing to explore the possibility of employment at subsequent service planning meetings for a member who is not employed in the community;
  • affirming or explaining how a member can work and still maintain current medical benefits (e.g., through the Medicaid Buy-In program), and in most cases will have an increase in income;
  • explaining rights to appeal if services are denied, reduced or terminated; and
  • monitoring whether the member and family are satisfied with the employment supports.

 

4922 Supported Employment Providers

Revision 18-0; Effective September 4, 2018

Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member, legally authorized representative (LAR) or authorized representative (AR) under the Consumer Directed Services (CDS) option. As a minimum, the SE provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the member, and satisfy one of these options:

Option 1:

  • Bachelor’s degree in rehabilitation, business, marketing, or a related human services field; and
  • six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

  • Associate’s degree in rehabilitation, business, marketing, or a related human services field; and
  • one year of paid or unpaid experience providing services to people with disabilities.

Option 3:

  • High school diploma or Certificate of High School Equivalency (General Educational Development (GED) credentials), and
  • two years of paid or unpaid experience providing services to people with disabilities.

Under the CDS option, the provider cannot be the member’s legal guardian or the spouse of the legal guardian.

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 Requirements

Revision 22-1; Effective January 31, 2022

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

  • be under 21 years of age; 
  • reside in Texas; 
  • meet the medical necessity (MN) for a nursing facility (NF) level of care (LOC) as determined by 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 service; 
  • choose MDCP as an alternative to NF services, as described in Title 42 Code of Federal Regulations (CFR) §441.302(d)
  • not be enrolled in another Medicaid Home and Community Based Services (HCBS) waiver program approved by Centers for Medicaid & Medicare Services (CMS); 
  • if the individual is under 18 years of age, resides: 
    • with a family member; or 
    • in a foster home that includes no more than four children unrelated to the individual; and 
  • be determined by HHSC to be financially eligible for Medicaid, as described in Title 1 TAC §358 (relating to Medicaid Eligibility for the Elderly and People with Disabilities), Title 1 TAC §360 (relating to Buy-In Program), or Title 1 TAC §361 (relating to Medicaid Buy-In for Children Program).
     

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 Sent Original ISP End Date Adverse Action Expiration Date: 12th Business Day Extend ISP in TMHP LTCOP for Adverse Action Form H2065-D Termination Date Member Requests State Fair Hearing Services Continue During State Fair Hearing?
6/12/20 7/31/20 6/30/20 No 7/31/20 7/15/20 Yes
6/1/20 6/30/20 6/17/20 No 6/30/20 7/2/20 No
6/25/20 6/30/20 7/13/20 Yes 7/31/20 7/17/20 Yes
6/25/20 6/30/20 7/13/20 Yes 7/31/20 7/13/20 Yes
8/28/20 8/31/20 9/15/20 Yes 9/30/20 9/14/20 Yes

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, 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 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, 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, or Form H2065-D, Notification of Managed Care Services, 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 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not live in an allowable living situation. PSU staff will deny or terminate the applicant or member on the last day of the month in which the 90th day occurs that the applicant or member has not returned to an allowable living arrangement. Title 42 CFR §441.301(c)(5) states the following living arrangements are not an allowable setting for the receipt of MDCP:

  • a nursing facility (NF);
  • an institution for mental diseases;
  • an intermediate care facility for individuals 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 on the grounds of, or immediately adjacent to, a public institution, or any other setting that has the effect of isolating individuals receiving Medicaid Home and Community Based Services (HCBS) from the broader community of individuals not receiving Medicaid HCBS is presumed to be a setting that has the qualities of an institution 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 that the setting does have the qualities of home and community-based settings.

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

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

The MCO must notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, 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 Managed Care Compliance Operations (MCCO) at PSU_Past_Due_Assessments@hhsc.state.tx.us advising that the MCO is not timely in their notification if the MCO fails to meet this notification time frame.

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;
  • 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) 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) record, if applicable;
  • invalidating 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;
  • 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.

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 following the instructions in Appendix II;
  • mailing Form H2065-D to the member or LAR;
  • uploading Form H2065-D to TxMedCentral following the instructions in Appendix IX;
  • adjusting the ISP end date to the termination effective date in the TMHP LTCOP and terminating the ISP record, following the instructions listed in Appendix I;
  • for MAO members, completing Form H1746-A following the instructions in Appendix XV and faxing to the MEPD specialist along with Form H2065-D;
  • for MAO members, emailing 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;
  • uploading applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • documenting and closing 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.

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.

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, 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:

  • 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, 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, 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 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 22-1; Effective January 31, 2022

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

  • the Social Security Administration (SSA) for Supplemental Security Income (SSI); or 
  • Medicaid for the Elderly and People with Disabilities (MEPD) for medical assistance only (MAO).

PSU staff receive notification of the denial of Medicaid financial eligibility for SSI and MAO applicants and members from the Loss of Eligibility Report (LOE). The applicant or member may appeal the:

  • SSI denial through SSA; or
  • Medicaid denial through MEPD. 

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, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • mail the applicant or legally authorized representative (LAR):
    • Form H2065-D;
    • Form H1200, Application for Assistance – Your Texas Benefits, if applicable; and
    • Form 2606, Managed Care Enrollment Processing Delay, if applicable;
  • upload Form H2065-D on TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • 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:

  • create a new HEART case record, if applicable;
  • verify Medicaid financial eligibility has been terminated by reviewing the Texas Integrated Eligibility Redesign System (TIERS) Medicaid/CHIP/CHIP Perinatal History;
  • manually generate Form H2065-D following the instructions in Appendix II;
  • ensure the termination date on Form H2065-D matches the Medicaid termination date; 
  • mail the member or LAR:
    • Form H2065-D;
    • Form H1200; and
    • Form 2606; 
  • upload Form H2065-D on TxMedCentral following the instructions in Appendix IX;
  • adjust the ISP end date to the Medicaid financial termination 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:

  • 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 prior to the termination effective date

PSU staff must refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, if an MAO member requests a fair hearing with continued benefits within the adverse action notification period. PSU staff must extend the ISP until the outcome of the fair hearing decision if the Centralized Representative Unit (CRU) advises PSU staff that the member may receive continued benefits during the fair hearing. 

The termination effective date in the TMHP LTCOP for members with SSI or MAO members must match the TIERS Medicaid/CHIP/CHIP Perinatal History segment’s end date. This is true even if the TIERS end date is in the past.

The chart below depicts examples of PSU staff actions when:

  • the MEPD specialist terminates a member due to not meeting MDCP financial eligibility and the member has not requested a state fair hearing with continued benefits within the adverse action notification period; or
  • SSA terminates a member with SSI.
TIERS Date for Loss of Financial Eligibility Date PSU Informed Eligibility Lost Current TMHP LTCOP ISP End Date Date Form H2065-D Sent Form H2065-D Termination Date TMHP LTCOP Data Entry

12-31-2016

12-31-2016 5-31-2017 1-2-2017 12-31-2016 ISP end date must be corrected to 12-31-2016.
12-31-2016 12-31-2016 5-31-2017 11-2-2017 12-31-2016 ISP end date must be corrected to 12-31-2016.
12-31-2016 2-5-2017 5-31-2017 2-7-2017 12-31-2016 ISP end date must be corrected to 12-31-2016.

Notes:

  • The member can resume services if the MEPD specialist reestablishes the member’s Medicaid eligibility with a gap of six months or less. The MCO may use the existing 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 ISP and medical necessity (MN) are expired.
  • The member must go to the bottom of the interest list to reapply for services if the MEPD specialist reestablishes the member’s Medicaid eligibility within a gap of six months or more. 

 

6300.5  Medical Necessity and Level of Care

Revision 22-1; Effective January 31, 2022

Title 26 TAC §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 §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, or Form H2067-MC, Managed Care Programs Communication, 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, 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, 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;
  • 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, 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, 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 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) 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, 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, 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, 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, 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, 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, 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 Failure to Meet Other Program Requirements

Revision 22-1; Effective January 31, 2022
 
Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an applicant or member may need to be denied or terminated due to failure to meet other program requirements not listed in Section 6300.1 through Section 6300.8. The PSU supervisor will notify PSU staff if the denial or termination can be processed. PSU staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not meet the eligibility requirements as noted in Title 1 Texas Administrative Code (TAC) §353.1155. PSU staff must process a case closure upon notification that an individual fails to meet other program requirements.

PSU staff may receive notification that an individual, applicant or member does not meet other program requirements by:

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

PSU staff must complete the following activities for individuals within two business days of 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 H2067-MC, Managed Care Programs Communication, 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 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;
  • 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 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; and
  • document and close the HEART case record.

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


The applicability of the adverse action notification period is scenario specific. PSU staff must allow for the adverse action notification time frame to expire for MAO members before terminating the ISP, if adverse action is applicable. 

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 prior to the termination effective date.

Refer to Section 6200, Adverse Action Notification Period, for additional information on determining the termination effective date if the PSU supervisor determines the adverse action notification period is applicable.

Note: The adverse action notification period applies for transitions to adult programs. PSU staff do not need to notify their supervisor as directed above for transitions to adult programs.

 

6300.10 Other Reasons

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an applicant or member may need 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 denial or termination reason can be processed. PSU staff must deny or terminate Medically Dependent Children Program (MDCP) eligibility when an applicant or member does not meet the MDCP eligibility requirements as noted in Title 1 Texas Administrative Code (TAC) §353.1155. PSU staff must process a case closure for individuals who require case closure for other reasons.

PSU staff must complete the following activities for individuals within two business days of 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 H2067-MC, Managed Care Programs Communication, 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 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 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 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 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.

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

Refer to Section 6200, Adverse Action Notification Period, for additional information on determining the termination effective date if the supervisor determines the adverse action notification period is applicable.

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, 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.

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 Program Support Unit Staff Procedures for Completing Form H4800

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff may receive a request for a state fair hearing related to Medically Dependent Children Program (MDCP) eligibility from an applicant, member, parent, guardian, or legally authorized representative (LAR) orally or in writing. When a state fair hearing request is received, PSU staff must create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials, within five days from the date of the request.

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.

Upon receipt of the state fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary. PSU staff send Form H4800 to the data entry representative (DER) and DER supervisor within three days of the request for a state fair hearing. The three-day time frame allows the DER two days to enter the information on Form H4800 in TIERS.

PSU staff must use Form H4800 to record the names of all persons who should attend the state fair hearing.

Depending on the issue being appealed, PSU staff must enter the following staff on Form H4800:

  • For medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP):
    • TMHP representative as the “Agency Representative”;
    • TMHP supervisor as the “Agency Supervisor”;
    • MCO representative and MCO supervisor as the “Agency Witness”; and
    • PSU staff and PSU supervisor as the “Observer.”
  • For Supplemental Security Income (SSI) denial by Social Security Administration (SSA):
    • PSU staff as the “Agency Representative”;
    • PSU supervisor as the “Agency Supervisor”;
    • MCO representative and MCO supervisor as the “Agency Witness”; and
    • no “Observer” may be listed unless otherwise specified (e.g., a family member).
  • For other denial reasons (excluding MEPD or TW financial denials):
    • MCO representative as the “Agency Representative”;
    • MCO supervisor as the “Agency Supervisor”;
    • MCO representative as the “Other Participants”; and
    • PSU staff and PSU supervisor as the “Observer.”

PSU staff should contact the MCO if there is any doubt as to who should be listed on Form H4800.

When PSU staff complete Form H4800, all questions in Section 1 must be answered. PSU staff must always answer “No” to the question, “Appeal requested timely within 10 calendar days of agency action?”, as this question applies only to TW programs. PSU staff must indicate the individual service plan (ISP) begin and end dates, as applicable, in the section labeled “Summary of agency action and applicable handbook reference(s) or rules.”

PSU staff must indicate the ISP begin and end dates, as applicable, in the section labeled “Summary of agency action and applicable handbook reference(s) or rules” on Form H4800. The begin and end dates must also be mentioned during the state fair hearing so the hearings officer is aware of when the ISP year ends when rendering a hearing decision regarding the MDCP denial.

Refer to Form H4800 instructions for more specific directions for form completion and transmittal.

 

7211 Data Entry Representative Procedures for Entering the State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

When the data entry representative (DER) receives Form H4800, Fair Hearing Request Summary, from Program Support Unit (PSU) staff, the DER creates a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record to document the state fair hearing request. The HEART case record and Community Services Interest List (CSIL) database record is to remain open until a state fair hearing decision is rendered.

Within two business days of receipt of Form H4800, the DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS). The DER must use the Manage Office Resources (MOR) Search function in TIERS when adding PSU, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP) or Texas Health and Human Services Commission (HHSC) representatives as participants. When entry of all information is complete, TIERS assigns the appeal identification (ID) number. The DER sends a copy of the TIERS generated Form H4800 to PSU staff and uploads to the HEART case record.

 

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:

  • Form H4800;
  • Form H4803;
  • Form H4805, Fair Hearing Procedures; and
  • Form H4806, Request for Another Appointment - Request to Withdraw.

 

7213 State Fair Hearing Packet

Revision 22-1; Effective January 31, 2022

Each entity involved in the state fair hearing process is responsible for preparing its own state fair hearing packet, uploading documents to the Texas Health and Human Services Commission (HHSC) Benefits Portal, and mailing the documents to the applicant, member or legally authorized representative (LAR) within ten days from the date of the fair hearing request. Refer to Section 7231, Uploading the State Fair Hearing Evidence Packet to the HHSC Benefits Portal, for uploading instructions. Program Support Unit (PSU) staff must ensure documentation on Form H4800, Fair Hearing Request Summary, clearly states this is a state fair hearing for the Medically Dependent Children Program (MDCP). All state fair hearing packets must be complete, organized and all pages numbered to support the agency’s action on an appeal.

The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials. 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.

The following are examples of documentation that must be submitted as evidence and the entity responsible for uploading that information in the HHSC Benefits Portal and mailing documents to the applicant, member, LAR or AR:

  • Managed care organization (MCO):
    • MCO policy handbook, STAR Kids Handbook (SKH), STAR Kids Contract, Uniform Managed Care Contract (UMCC) or Uniform Managed Care Manual (UMCM);
    • summary of events;
    • other documentation supportive of the determination, such as documentation of telephone calls and visit summaries; and
    • copies of the signed Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and all relevant attachments.
  • PSU:
    • For Supplemental Security Income (SSI) denials:
    • For medical necessity (MN) denials:
      • a copy of Form H4803;
      • a copy of Appendix XVII;
      • a copy of the citation from Title 26 TAC §554.2401;
      • a copy of Section 6300.5, Medical Necessity and Level of Care;
      • a copy of Form H2065-D;
      • for applicants, a copy of Appendix XXVII, MDCP Medical Necessity Denial Attachment; and
      • for members, a copy of Attachment B, Fair Hearing and Interest List Options for MDCP Denials.
  • CRU:
    • relevant sections of the MEPD HandbookSTAR Kids Handbook, other state or federal rules or regulations;
    • documentation supportive of the financial determination, including official documentation forms, telephone calls, etc.; and
    • a copy of Form H2065-D.
  • Texas Medicaid & Healthcare Partnership (TMHP):
    • relevant sections of the TAC and other state or federal rules or regulations;
    • a copy of the STAR Kids Screening and Assessment Instrument (SK-SAI) tool; and
    • other documentation supporting the determination.

The applicant, member or LAR should fax or mail the evidence to the hearings officer if the applicant, member or LAR wants to submit evidence for the state fair hearing. Form H4803 lists the hearings officer’s contact information. The hearings officer shares any evidence submitted by the applicant, member, LAR or AR with HHSC.

 

7214 Changes to the State Fair Hearing Request Summary

Revision 18-0; Effective September 4, 2018

After the data entry representative (DER) has added information from Form H4800, Fair Hearing Request Summary, in the Texas Integrated Eligibility Redesign System (TIERS), except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Woks (TW) financial denials, Program Support Unit (PSU) staff may learn of subsequent changes such as change of address. 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. When subsequent changes occur, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the DER who will check TIERS to identify if a hearings officer has been assigned to the case. The DER must ensure documentation on Form H4800-A clearly states this is a state fair hearing for Medically Dependent Children Program (MDCP). The appeal identification (ID) number assigned by TIERS must be documented in the designated space on Form H4800-A.

If a hearings officer is assigned, the DER must upload Form H4800-A in the Texas Health and Human Services Commission (HHSC) Benefits Portal as soon as possible, but no later than 10 days of becoming aware of the change.

Delays in uploading documentation may delay a state fair hearing or require a state fair hearing be rescheduled.

 

7220 Processing a State Fair Hearing Request

Revision 18-0; Effective September 4, 2018

 

7221 Type of Denials

Revision 18-0; Effective September 4, 2018

An applicant, member, parent, guardian or legally authorized representative (LAR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form H4800, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member, or legally authorized representative (LAR) requests a state fair hearing for program denials. PSU staff notify the Centralized Representative Unit (CRU) if it is a Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial using the Texas Health and Human Services Commission (HHSC) Benefits Portal. PSU staff create all other state fair hearing request in TIERS. The method in which the state fair hearing is requested depends on the action being appealed. PSU staff must determine if the state fair hearing action is:

  • a medical necessity (MN) denial (Refer to Section 7221.1, Medical Necessity Denial by Texas Medicaid & Healthcare Partnership);
  • a financial denial by MEPD or TW (Refer to Section 7221.2, Financial Denial by Medicaid for the Elderly and People with Disabilities or Texas Works);  
  • a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA) (Refer to Section 7221.3, Supplemental Security Income Denial by the Social Security Administration); or
  • for any other denial reasons (Refer to Section 7221.4, Other Denial Reasons).

 

7221.1 Medical Necessity Denial by Texas Medicaid & Healthcare Partnership

Revision 18-0; Effective September 4, 2018

If the action is related to a medical necessity (MN) denial by Texas Medicaid & Healthcare Partnership (TMHP), the managed care organization (MCO) and TMHP representatives are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff upload Form H2065-D, Notification of Managed Care Program Services (a signed copy, if available), to the Texas Health and Human Services Commission (HHSC) Benefits portal to allow the TMHP representative to include Form H2065-D in TMHP’s evidence packet. PSU staff do not attend state fair hearings for MN denials.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the TMHP representative and TMHP supervisor as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

  • TMHP representative as the “Agency Representative”;
  • TMHP supervisor as the “Agency Representative Supervisor”;
  • MCO representative and MCO supervisor as the “Agency Witness”; and
  • PSU staff and PSU supervisor as the “Observer.”

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "Observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to an MN denial, on the “Agency Representative” field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

When Form H4800 is sent to the DER, PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while an MN denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the MN 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.

 

7221.2 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 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff must prepare the evidence packet and attend the state fair hearing for Supplemental Security Income (SSI) denials by the Social Security Administration (SSA). Refer to Section 7230, State Fair Hearing Actions, for PSU staff responsibilities for preparing the state fair hearing evidence packet.

The following are examples of documentation that PSU staff must submit as evidence and are responsible for uploading in the Texas Health and Human Services (HHSC) Benefits Portal:

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the PSU staff and PSU supervisor as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the "Other Participants" tab to enter the following:

  • PSU staff as the “Agency Representative”;
  • PSU supervisor as the “Agency Representative Supervisor”;
  • MCO staff as the “Agency Witness”; and
  • no “Observer” may be listed unless otherwise specified (e.g, a family member).

The MOR search function assures that all the correct information populates in TIERS, and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the “Agency Representative" and “Agency Representative Supervisor” can view state fair hearing notices using the Alert tab in TIERS.

PSU staff are required to select "No" in the drop-down menu in the “Agency Representative” field in TIERS in Section 6 that asks: "Are you an OES MEPD or TW employee?"

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing does not apply for SSI denials. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information. 

PSU staff must not put an applicant’s or member’s name back on the MDCP interest list while an SSI denial is in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case or resume services once the hearings officer renders a decision on the SSI denial. The applicant or member may choose to be added back to the MDCP interest list if the hearings officer sustains the denial.

The PSU staff and PSU supervisor entered as "Agency Representative" and “Agency Representative Supervisor” receive an alert in TIERS when the hearings officer renders a state fair hearing decision. 

Refer to Section 7500, State Fair Hearing Decision Actions, for additional information about notification requirements for required actions following a state fair hearing decision.

 

7221.4 Other Denial Reasons

Revision 18-0; Effective September 4, 2018

Other denial reasons include, but not limited to:

  • unable to locate the applicant or member;
  • unable to obtain physician signature; or
  • cost of the individual service plan (ISP) exceeds the maximum amount allowed.

If the action is related to other denial reasons, the managed care organization (MCO) staff are required to prepare the evidence packet and attend the state fair hearing. Program Support Unit (PSU) staff do not attend state fair hearings related to other denial reasons.

PSU staff complete Form H4800, Fair Hearing Request Summary, entering the MCO contact as the "Agency Representative" and "Agency Representative Supervisor."

The data entry representative (DER) uses the Manage Office Resources (MOR) search function in the Texas Integrated Eligibility Redesign System (TIERS) in the Other Participants tab to enter the following:

  • MCO staff as the “Agency Representative”;
  • MCO supervisor as the “Agency Representative Supervisor”;
  • MCO staff as the “Agency Witness”; and
  • PSU staff and PSU supervisor as the “Observer.”

The MOR search function assures that all the correct information is populated in TIERS and each entity receives the notice of the state fair hearing. PSU staff and the PSU supervisor listed as the "Observer" will be able to view state fair hearing notices using the Alert tab in TIERS.

For a state fair hearing decision relating to other denial reasons, on the "Agency Representative" field in TIERS, the question in Section 6 asks: "Are you an OES MEPD or TW employee?", PSU staff are required to select "No" in the drop-down.

When Form H4800 is sent to the data entry representative (DER), PSU staff send an email notification regarding the request for a state fair hearing to the Centralized Representative Unit (CRU) for continued benefits, if the state fair hearing request is filed by the effective date of the action pending the state fair hearing. Refer to Section 7222.1, Continuation of Medically Dependent Children Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the MDCP interest list while other denial reasons are in the state fair hearing process. PSU staff must take appropriate action to certify or deny the case, or resume services once the other denial reasons 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, the PSU staff and 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.

 

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 22-1; Effective January 31, 2022

Continuation of Medically Dependent Children Program (MDCP) benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials. For all other denials, MDCP must continue until the hearings officer issues a decision if the member or legally authorized representative (LAR) files a state fair hearing requesting continued benefits:

  • within the adverse action notification period of the MDCP termination; or
  • by the effective date of the action pending the state fair hearing.

The deadline is whichever date is later.

Program Support Unit (PSU) staff must notify the following parties within three business days if the member requests a state fair hearing within the adverse action notification period or by the effective date of the action: 

  • the managed care organization (MCO) by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO to continue providing services until the hearings officer renders a decision. PSU staff must also upload a copy of Form H2067-MC in 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
  • the Centralized Representation Unit (CRU) by email at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox, including: 
    • a subject line that reads: MDCP Request for Continued Benefits– XXX.XXX [first three letters of the applicant’s or member’s first and last name] #### [last four digits of the case number];
    • applicant or member name;
    • Medicaid identification (ID) number;
    • HHSC Benefits Portal Appeal ID number, if available;
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service (MDCP);
    • reason for termination (e.g., medical necessity denial);
    • specific information requesting the Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denial 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 regarding MN;
  • a copy of Form H2067-MC from the managed care organization (MCO) indicating the member requested continued benefits, if applicable;
  • a copy of Form H2065-D, Notification of Managed Care Program Services; and
  • the witnesses’ contact information such as the MCO representative and the designated MCO back-up.

PSU staff must extend the current individual service plan (ISP) for four months or until the state fair hearing decision is rendered if the hearings officer’s decision will not be made until after the ISP expiration date. PSU staff must not mail Form H2065-D to the member or legally authorized representative (LAR) notifying of continued eligibility until the hearings officer renders a state fair hearing decision.

Example: The member’s four-month period would end on the last day of April if the ISP expiration date is December 1 and the state fair hearing decision date is December 15.

HHSC continues or reinstates services pending the state fair hearing decision if the state fair hearing is initially dismissed and then subsequently reopened, and the member or LAR requests continued services. The hearings officer, in effect, voids the prior state fair hearing decision if the hearings officer sets a date for a new state fair hearing. The member must continue to receive services until the hearings officer renders a new state fair hearing decision. 

 

7222.2 Termination of MDCP Services Due to a Member Not Requesting a State Fair Hearing

Revision 18-0; Effective September 4, 2018

If the state fair hearing is not filed by the effective date of the action, Medically Dependent Children Program (MDCP) services continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If the state fair hearing was not requested by the effective date of the action, Program Support Unit (PSU) staff must process according to the following:

  • For Medical Assistance Only (MAO) members:
    • post Form H2065-D to TxMedCentral, noting MDCP will be terminated effective the day after the date noted on Form H2065-D and following the instructions in Appendix IX, Naming Conventions;
    • for medical necessity (MN) denials, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to MEPD noting Medicaid coverage will need to be terminated effective the day immediately following the MDCP termination date noted on Form H2065-D;
    • email Enrollment Resolution Services (ERS) at HPO_STAR_PLUS@hhsc.state.tx.us, requesting the member be disenrolled from STAR Kids following the disenrollment policy effective the day immediately following the ISP expiration date. The mail must include:
      • a subject line that reads: Request for Termination - STAR Kids MDCP MN Denial Appeal ID-XXXXXXX;
      • applicant or member name;
      • Medicaid identification (ID) number (if applicable);
      • termination effective date;
      • a copy of Form H1746-A;
      • a copy of Form H2065-D; and
      • a copy of Form H2067-MC, Managed Care Programs Communication.
  • For Supplemental Security Income (SSI) members, Form H2067-MC must be posted to TxMedCentral, following the instructions in Appendix IX, to inform the managed care organization (MCO) that MDCP services should only continue until the effective date of the action, which is usually the expiration date of the ISP.

SSI members will remain enrolled in a STAR Kids MCO and are still eligible for State Plan services, which include acute care and long term services and supports (LTSS), such as Community First Choice (CFC), Day Activity and Health Services (DAHS), Emergency Response Services (ERS), and personal assistance services (PAS).

 

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 18-0; Effective September 4, 2018

The data entry representative (DER) must upload all evidence packets and all supporting documentation for Supplemental Security Income (SSI) denials and medical necessity (MN) denials in the Texas Health and Human Services Commission (HHSC) Benefits Portal using the process described below. Refer to Section 7213, State Fair Hearing Packet, for examples of documentation that must be submitted as evidence.

At least 12 business days prior to the state fair hearing date, the DER must:

  • upload the supporting documentation into the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
  • email the supporting documentation to Program Support Unit (PSU) staff and the PSU supervisor.

Within two business days after receipt of the evidence packet in the HHSC Benefits Portal, the DER must:

  • select the Appeals/RFR tab and ensure the appeal has been entered;
  • 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); and
  • select Upload.

If an error is made on the “Agency Representative” screen when creating an appeal in the Texas Integrated Eligibility Redesign System (TIERS), the person who created the appeal can correct the error in “Maintain Appeals.” If an error is made on any other screen when creating an appeal in TIERS, Form H4800-A, Fair Hearing Request Summary (Addendum), must be completed and uploaded in the HHSC Benefits Portal. The “Agency Action Date” cannot be changed.

 

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 18-0; Effective September 4, 2018

After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or legally authorized representative (LAR) and copies all individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff and the PSU supervisor. If the decision is sustained, the PSU staff take the appropriate action.

If the state fair hearing decision is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The hearings officer renders a decision and sends the written decision to the applicant, member or LAR and copies all the individuals listed on Form H4800, which includes the PSU staff and PSU supervisor. PSU staff actions required by the hearings officer must be reported back in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation screen, within the 10-day time frame designated by the hearings officer.

If the applicant, member or LAR requested continued services during the state fair hearing period, PSU staff follow procedures described in Section 7500, State Fair Hearing Decision Actions.

7300, Post State Fair Hearing Actions

7310 Action Taken on the State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the PSU supervisor and data entry representative (DER). PSU staff must send Form H4807 within the 10-day time frame designated by the hearings officer to allow at least two business days for the DER to enter the information in the Texas Integrated Eligibility Redesign System (TIERS). If the action cannot be taken within the time frame designated by the hearings officer, Form H4807 is completed and sent to the PSU supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on Form H4807; the begin delay date and end delay date must be included. Refer to Form H4807 instructions for more specific directions for form completion and transmittal.

7500, State Fair Hearing Decision Actions

7510 Sustained State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018

When a hearings officer renders a sustained decision, the denial is upheld. 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), essentially sustaining the action on appeal. Refer to Section 7511, Sustained Decision – Termination Effective Date, to determine the correct Medically Dependent Children Program (MDCP) termination effective date to include on forms and notifications.

When the hearings officer’s decision sustains the denial of MDCP, Program Support Unit (PSU) staff must:

  • notify the managed care organization (MCO) by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix IX, Naming Conventions, noting for the MCO to deliver services through the MDCP termination effective date, if services were continued during the state fair hearing process;
  • terminate MDCP services by end-dating the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal effective the MDCP termination effective date;
  • email Form H1746-A, MEPD Referral Cover Sheet, to the Centralized Representation Unit (CRU) at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox, of the hearings officer’s decision and the termination effective date for Medical Assistance Only (MAO) members. The CRU will terminate Medicaid eligibility for MAO members; and
  • email Enrollment Resolution Services (ERS) at HPO_STAR_PLUS@hhsc.state.tx.us of the hearings officer’s decision and the termination effective date for MAO members. ERS will disenroll MAO members from MDCP. The email must include:
    • a subject line that reads: Hearings Officer Decision – STAR Kids MDCP – Sustained Appeal ID-XXXXXXX;
    • applicant or member name;
    • Medicaid identification (ID) number (if applicable);
    • type of service (MDCP);
    • termination effective date;
    • a copy of Form H1746-A;
    • a copy of Form H2067-MC; and
    • a copy of the state fair hearing decision.

PSU staff must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the applicant, member authorized representative (AR) or legally authorized representative (LAR) of the sustained denial.

 

7511 Sustained Decision – Termination Effective Date

Revision 18-0; Effective September 4, 2018

When Medically Dependent Children Program (MDCP) services are terminated at reassessment because the applicant or member does not meet eligibility criteria and services are continued until the state fair hearing decision is known, the termination effective date will vary depending on the following circumstances:

  • In cases where the hearings officer’s decision is 30 days or more prior to the end of the individual service plan (ISP) in effect when the state fair hearing was filed, MDCP termination is effective at the end of the ISP in effect at the time the state fair hearing was filed. Refer to Example 1 below.
  • When the hearings officer’s decision date is less than 30 days before the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that is 30 days from the hearings officer’s decision date (the date the order is signed). Refer to Example 2 below.
  • When the hearings officer’s decision date is after the end of the ISP in effect when the state fair hearing was filed, and a new ISP was developed to continue services past the ISP end date until the state fair hearing decision was made, the termination effective date is the end of the month that is 30 days from the hearings officer’s decision date. Refer to Example 3 below.
  • If the hearings officer assigns a specific medical necessity (MN) or ISP expiration date not equal to the last day of the month but after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month that the hearings officer identified as the expiration month. Refer to Example 4 below.
  • When the hearings officer assigns a specific MN or ISP expiration date equal to the last day of the month, and this date is equal to or after the end of the ISP in effect when the state fair hearing was filed, the termination effective date is the end of that ISP period. Refer to Example 5 below.
  • If the hearings officer assigns a specific MN or ISP expiration date that is before the end of the MN or ISP in effect when the state fair hearing was filed, the termination effective date is the end of the month of the original MN or ISP expiration date. Refer to Example 6 below.

Examples

Example Conditions Original
MN/ISP
Expiration
Date
New Expiration
Date
Hearings Officer
Decision Date
Final
MN/ISP Expiration
Date
1 Hearings officer decision is more than 30 days from the original expiration date. 1/31/18 5/31/18 11/30/17 1/31/18
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/18 5/31/18 1/15/18 2/28/18
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/18 5/31/18 2/15/18 3/31/18
4 Hearings officer decision assigns a specific expiration date. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/15/18. 2/28/18
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 2/28/18. 2/29/18
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/18 5/31/18 Hearings officer decision was for MN or ISP to expire on 12/31/17. 1/31/18

 

7520 Reversed State Fair Hearing Decision

Revision 18-0; Effective September 4, 2018

When the hearings officer’s decision reverses the denial of the Medically Dependent Children Program (MDCP) for an applicant or member, within two business days Program Support Unit (PSU) staff must:

  • notify the managed care organization (MCO) by posting Form H2067-MC, Managed Care Programs Communication, that MDCP services are to continue as directed in the hearings officer’s decision and to request Form 2603, STAR Kids Individual Service Plan (ISP) Narrative;
  • send Form H2065-D, Notification of Managed Care Program Services, to the:
    • applicant who was denied at application to notify him or her of eligibility for MDCP for the new ISP year;
    • member who was terminated at reassessment to notify him or her that the denial decision was reversed and he or she is eligible for MDCP for the new ISP year;
    • MCO regarding the MDCP effective date for the applicant or member;
    • Enrollment Resolution Services (ERS) by email at HPO_STAR_PLUS@hhsc.state.tx.us. The email must include:
      • a subject line that reads: Hearings Officer Decision – STAR Kids MDCP – Reversed Appeal ID-XXXXXXX;
      • applicant or member name;
      • Medicaid identification (ID) number (if applicable);
      • MDCP effective date;
      • Medicaid eligibility effective date;
      • managed care effective date;
      • a copy of Form H1746-A, MEPD Referral Cover Sheet, if applicable;
      • a copy of Form H2065-D;
      • a copy of Form H2067-MC; and
      • a copy of the state fair hearing decision.
  • ensure the ISP is registered or updated in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal with the correct effective dates; and
  • email Form H1746-A to the Centralized Representation Unit (CRU) at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox, as appropriate, to continue Medicaid eligibility. The email must include:
    • a subject line that reads: Reinstatement of Benefits for MDCP – Appeal ID -XXXXXXX;
    • applicant or member name;
    • Medicaid ID number (if applicable);
    • type of service (MDCP);
    • Medicaid eligibility effective date; and
    • a copy of the state fair hearing decision.

 

7521 Reversed Decision – Effective Date

Revision 18-0; Effective September 4, 2018

When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) eligibility, the effective date for:

  • applicants – an initial application is the first of the month following the hearings officer’s decision; or
  • members – a reassessment is one day after the end of the individual service plan (ISP) in effect when the state fair hearing was filed.

When a state fair hearing decision reverses a Program Support Unit (PSU) program denial but PSU staff cannot implement the state fair hearing decision within the required time frame, PSU staff must complete Section C, Implementation Delays, on Form H4807, Action Taken on Hearing Decision. PSU staff must attach and send Form H4807 by email to the data entry representative (DER). Information on Form H4807 must be entered by the DER on the Decision Implementation screen in the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Refer to Section 7233, State Fair Hearing Decision, and Section 7310, Action Taken on the State Fair Hearing Decision, for the required time frames.

PSU staff may need to coordinate effective dates of reinstatement with the Central Representation Unit (CRU).

PSU staff report the implementation of the state fair hearing decision in TIERS on Form H4807 according to current procedures.

 

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 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) hearings officer:

  • notifies all hearing participants of the date and time of the state fair hearing;
  • prepares a final order disposing of a case through withdrawal and sends copies of this order to the applicant, member or legally authorized representative (LAR) and Program Support Unit (PSU) staff upon written notification from the applicant, member or LAR to withdraw a state fair hearing;
  • conducts the state fair hearing;
  • considers all testimony and exhibits in making a decision;
  • reserves the right to hold a hearing record open after a state fair hearing to obtain additional information;
  • renders a state fair hearing decision; and
  • sends a written copy of all state fair hearing decisions to the applicant, member or LAR, Texas Medicaid & Healthcare Partnership (TMHP) and PSU staff within five days of making the decision.

Administrative review of any hearings officer’s decision provided in the state fair hearings must be initiated by the applicant, member or LAR.

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 22-4; Effective March 4, 2022

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 that is not covered in Appendix II.

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-D Reason for Denial in Plain Language Comments in Plain Language SKOPH Section
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.

No additional comment should be added. 6300.6
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.

No additional comment should be added. 6300.3
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); STAR+PLUS HCBS program; 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 Servicios en el Hogar y en la Comunidad de STAR+PLUS; 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.

6110
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.

No additional comment should be added. 6300.4
Medicaid Eligibility Reinstated within Four Months No 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/A
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.

No additional comment should be added. 6300.10
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 § 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).

No additional comment should be added. 6300.2
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.

No additional comment should be added. 6300.9
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.

No additional comment should be added. 6300.8
Medical Necessity and Level of Care Reason for denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

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.

6300.5
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.

No additional comment should be added. 6300.7
Initial Form H2065-D for MAO MFP to Community No reason for denial language should be added.

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.

Usted 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/A
Initial Form H2065-D for MFP to AFC No reason for denial language should be added.

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/A
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.

No additional comment should be added. 2428
Room and Board and Copayment No reason for denial language should be added.

You must pay room and board and any copayment. You will pay them every month to your foster care home or assisted living facility.

Usted 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/A
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 §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].

6300.2
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.

No additional comment should be added. 6300.10
Over Age 20

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.

No additional comment should be added. 6300.9
Other Contact supervisor. No additional comment should be added. 6300.10

Appendix XVIII, STAR Kids HEART Naming Conventions

Revision 22-1; Effective January 31, 2022

This appendix outlines the screenshots Program Support Unit (PSU) staff 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 screenshots are 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 include 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 in the HEART transaction.

Interest List Release (ILR)

Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS *
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL CLOSURE Yes
Form 2442 (English) 2442 *
Form 2442-S (Spanish) 2442-S *
Form 2602 2602 Yes
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-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 H2053-B 2053B *
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 TxMedCentral 2065 TXMED *
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H3676-A Use TxMedCentral Naming Convention Yes
Form H3676-A Upload to TxMedCentral 3676A TXMED Yes
Form H3676-B Use TxMedCentral Naming Convention Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL *
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

Note: PSU staff must upload Form 2442 or Form H2065-D in the HEART case record, as appropriate.

Money Follows the Person (MFP)

Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual- Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS *
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
CSIL Closure Screenshot CSIL CLOSURE Yes
Form 2602 2602 Yes
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form 3618 3618 Yes
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 H2053-B 2053B *
Form H2065-D Generated in TMHP LTC Online Portal (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL *
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

Annual Reassessment

Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS *
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
Form 2604 (if received through TMHP LTCOP) LTCOP ISP Yes
Form 2604 (if received through TxMedCentral) Use TxMedCentral Naming Convention Yes
Form 2606 2606 *
Form 2606-S 2606-S *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from MCCO MCCO EMAIL *

Transition to Adult Programs (MDCP Age-Out)

Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TIERS LTSS Eligibility Periods Details Screenshot TIERS LTSS *
SASO Service Authorization Screenshot SASO SA *
CARE Screenshot CARE *
Form 2606 2606 *
Form 2606-S 2606-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 H2053-B 2053B *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H2116 2116 *
Emails for PSU QA Process QA EMAIL *
Emails to and from CCSE CCSE EMAIL *
Emails to and from ERS ERS EMAIL *
Emails to and from Higher Needs Coordinator HN EMAIL *
Emails to and from ILM Unit ILM EMAIL *
Emails to and from MCCO MCCO EMAIL *
Emails to and from STAR+PLUS PSU PSU EMAIL *
Emails to and from UR UR EMAIL *
MEPD Communication Tool MEPD EMAIL *

Denials and Terminations

Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
CSIL Closure Screenshot CSIL CLOSURE *
Fair Hearing Options for MDCP Denials MN DENIAL ATCH *
Fair Hearing and Interest List Options for MDCP Denials ATCH B *
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from ERS ERS EMAIL *
Emails to and from MCCO MCCO EMAIL *
MEPD Communication Tool MEPD EMAIL *

Fair Hearings

Item HEART Naming Convention Required
Form 2606 2606 *
Form 2606-S 2606-S *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF *
Form H2065-D Generated in TMHP LTCOP (English and Spanish) 2065 Yes
Form H2065-D Generated Manually (English and Spanish) Use TxMedCentral Naming Convention Yes
Form H2065-D Screenshot of Upload to TxMedCentral 2065 TXMED Yes
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Form H4800 4800 *
Form H4800-A 4800A *
Form H4800-D 4800D *
Form H4803 4803 Yes
Form H4806 4806 *
Form H4807 4807 *
Copy of TAC §353.1155 for SSI and MN Denials TAC 353.1155 Yes
Copy of Section 6300.4 for SSI Denials SKOPH 6300.4 Yes
Copy of Section 6300.5 for MN Denials SKOPH 6300.5 Yes
Fair Hearing Options for MDCP Denials MN DENIAL ATCH Yes
Fair Hearing and Interest List Options for MDCP Denials ATCH B Yes
Notice of Hearing Officer’s Decision APPEAL DECISION LTR Yes
HHSC Benefits Portal Screenshot of Hearing Officer's Decision TIERS APPEAL DECISION Yes
Emails to and from CRU CRU EMAIL *
Emails to and from ERS ERS EMAIL *
MEPD Communication Tool MEPD EMAIL *

Disenrollment

Item HEART Naming Convention Required
TIERS Individual - Medicaid History Screenshot TIERS ME Yes
TIERS Individual - Managed Care Screenshot TIERS MC Yes
TMHP LTCOP ISP Termination Screenshot DISENISP *
Form H1746-A (form alone or with fax confirmation page) 1746 *
Form H1746-A Fax Confirmation (if confirmation page only) 1746 CONF *
Form H2067-MC Use TxMedCentral Naming Convention Yes
Form H2067-MC Screenshot of Upload to TxMedCentral 2067 TXMED Yes
Medicaid Managed Care Member Disenrollment Form DISENFORM Yes
Emails for PSU QA Process QA EMAIL *
Emails to and from MCCO MCCO EMAIL Yes
MEPD Communication Tool MEPD 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.

B

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.

C

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.

E

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.

F

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.

G

Guardian — A person appointed as a guardian of the estate or of the person by a court.

H

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.

I

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.

L

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.

M

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.

N

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.

P

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.

Q

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.

R

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.

S

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.

T

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.

U

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.

V

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.

Form Title  
1579 Referral for Relocation Services ES
1581 Consumer Directed Services Overview ES
1582 Consumer Directed Services Responsibilities ES
1582-SRO Service Responsibility Option Roles and Responsibilities ES
1583 Employee Qualification Requirements ES
1584 Consumer Participation Choice ES
1585 Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES
1586 Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
1826-D Case Information Release  
2406 Physician Recommendation for Length of Stay in a Nursing Facility ES
2416 Minor Home Modifications and Adaptive Aids Service Authorization  
2442 Notification of Interest List Release Closure ES
2601 Physician Certification ES
2602 Application Acknowledgment ES
2603 STAR Kids Individual Service Plan (ISP) Narrative ES
2604 STAR Kids Individual Service Plan - Service Tracking Tool ES
2606 Managed Care Enrollment Processing Delay ES
3618 Resident Transaction Notice  
H0003 Agreement to Release Your Facts ES
H1097 Affidavit for Citizenship/Identity ES
H1746-A MEPD Referral Cover Sheet  
H1746-B Batch Cover Sheet  
H2053-B Health Plan Selection ES
H2065-D Notification of Managed Care Program Services ES
H2067-MC Managed Care Programs Communication  
H1200 Application for Assistance – Your Texas Benefits  
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination ES
H3676 Managed Care Pre-Enrollment Assessment Authorization  
H4800 Fair Hearing Request Summary  
H4800-A Fair Hearing Request Summary (Addendum)  
H4803 Notice of Hearing  
H4807 Action Taken on Hearing Decision  

22-2, Appendix II and Appendix XXVII Changes

Revision Notice 22-2; Effective March 4, 2022
 
The following change(s) were made:

Section Title Change
Appendix II Form H2065-D MDCP Reason for Denial and Comments Language Updates Section 6300.3 with 6110 for the denial reason, Enrolled in Another 1915(c) Medicaid Waiver.
Appendix XXVII MDCP Medical Necessity Denial Attachment Includes a source note for 26 Texas Administrative Code §554.2401, General Qualifications for Medical Necessity Determinations, on the file in English. The Spanish file already has the source note.

 

22-1, Miscellaneous Changes

Revision Notice 22-1; Effective January 31, 2022
 
The following change(s) were made:

Section Title Change
3328 Reassessment Notification Requirements Updates member reassessment notification requirements.
6050 Description Removes section.
6100 Description Renames section and moves the information previously in Section 6050, updates adverse action time frame requirements and adds miscellaneous changes.
6110 Medically Dependent Children Program Eligibility Requirements Deletes previous section titled Denial of Medical Necessity/Individual Service Plan and adds this section with adverse action time frame requirements and miscellaneous information.
6120 Denial of Medicaid Eligibility Removes section.
6130 Unable to Locate Removes section.
6200 Adverse Action Notification Period Renames section and moves the information previously in Section 6100, updates adverse action time frame requirements and adds miscellaneous changes.
6210 Denial/Termination Due to Death Removes section.
6220 Denial/Termination Due to Residence in a Nursing Facility Removes section.
6230 Denial/Termination Due to Member Request Removes section.
6240 Denial/Termination of Financial Eligibility Removes section.
6250 Denial/Termination of Medical Necessity Removes section.
6260 Denial/Termination Due to Inability to Locate the Member Removes section.
6270 Denial/Termination Due to Failure to Meet Other Program Requirements Removes section.
6280 Denial/Termination for Other Reasons Removes section.
6300 Denials and Terminations Renames section, moves the information previously in Section 6200 and adds miscellaneous changes.
6300.1 Death Adds a section with information previously in Section 6120, updates adverse action time frame requirements and adds miscellaneous changes.
6300.2 Living Arrangement is Not an Allowable Setting Adds a section with information previously in Section 6220, updates adverse action time frame requirements and adds miscellaneous changes.
6300.3 Voluntarily Declined Services Adds a section with information previously in Section 6230, updates adverse action time frame requirements and adds miscellaneous changes.
6300.4 Financial Eligibility Adds a section with information previously in Section 6240, updates adverse action time frame requirements and adds miscellaneous changes.
6300.5 Medical Necessity and Level of Care Adds a section with information previously in Section 6250, updates adverse action time frame requirements and adds miscellaneous changes.
6300.6 Unable to Locate Adds a section with information previously in Section 6130, updates adverse action time frame requirements and adds miscellaneous changes.
6300.7 Exceeding the ISP Cost Limit Adds a section with information previously in Section 6340, updates adverse action time frame requirements and adds miscellaneous changes.
6300.8 Failure to Obtain a Physician’s Signature Adds a section regarding the requirement to obtain the physician’s signature for initial assessments.
6300.9 Failure to Meet Other Program Requirements Adds a section with information previously in Section 6270, updates adverse action time frame requirements and adds miscellaneous changes.
6300.10 Other Reasons Adds a section with information previously in Section 6280, updates adverse action time frame requirements and adds miscellaneous changes.
6310 Denial/Termination Due to Threats to Health and Safety Removes section.
6320 Denial/Termination Due to Hazardous Conditions or Reckless Behavior Removes section.
6330 Denial/Termination Due to Harassment, Abuse or Discrimination Removes section.
6340 Denial as a Result of Exceeding the Cost Limit Removes section.
6350 Denial/Termination Due to Failure to Comply with Mandatory Program Requirements and Service Delivery Provisions Removes section.
6360 Denial/Termination Due to Failure to Pay Removes section.
6370 Denial/Termination Due to Other Reasons Removes section.
6400 Disenrollment Request Policy Adds a section for MCO disenrollment requests.
6500 ISPs Invalidated or Terminated in Error Adds a section for processing requirements related to ISPs invalidated or terminated in error.
7100 Reserved for Future Use Removes Managed Care Organization Procedures.
7110 Managed Care Organization Complaint Procedures Removes section.
7120 Internal Managed Care Organization Appeal Procedures Removes section.
7121 Expedited Managed Care Organization Internal Appeal Removes section.
7122 Requests for a State Fair Hearing After Exhausting Internal Managed Care Organization Appeals Removes section.
7213 State Fair Hearing Packet Updates state fair hearing packet requirements and adds miscellaneous changes.
7221.3 Supplemental Security Income Denial by the Social Security Administration Updates section references and links and adds miscellaneous changes.
7222.1 Continuation of Medically Dependent Children Program Services During a State Fair Hearing Updates PSU coordination requirements with AES and adds miscellaneous changes.
7232 Presentation of the State Fair Hearing Evidence Packet Updates section references and links and adds miscellaneous changes.
Appendix II Form H2065-D MDCP Reason for Denial and Comments Language Updates the “Purpose for Form H2065-D” column titles to reflect Section 6000 titles and sections to be used on Form H2065-D.
Appendix XVII MDCP Eligibility TAC Renames appendix.
Appendix XVIII STAR Kids HEART Naming Conventions Adds naming convention for Attachment B, updates naming conventions to reflect new SKOPH section titles and removes naming convention for 26 TAC 554.2401.
Appendix XXVII MDCP Medical Necessity Denial Attachment Updates adverse action time frame requirements.
Glossary Glossary Updates definitions for individual, applicant and member and adds miscellaneous changes.

 

21-10, Miscellaneous Changes

Revision Notice 21-10; Effective October 25, 2021

The following change(s) were made:

Section Title Change
1210 Medical Necessity Determination Removes the requirement for Program Support Unit (PSU) staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
1211 Medical Necessity Determination for an Individual or Applicant Residing in a Nursing Facility Changes the section title and removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
1212 Medical Necessity Determination for an Individual or Applicant Not Residing in a Nursing Facility Changes the section title and removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
1820 Managed Care Organization Notification Requirements for PSU Staff Changes the section title and removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2001 Eligibility Adds a section to include Texas Administrative Code (TAC) requirements for the Medically Dependent Children Program (MDCP) eligibility.
2002 Medical Necessity Adds a section to include TAC requirements for medical necessity.
2020 Interest List Management Unit Responsibilities Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2100 Enrollment Following Release from the Interest List Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2100.1 Individual Not Enrolled in Medicaid, Including an Individual Enrolled in the Children’s Health Insurance Program Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2100.2 Individual Who Receives Supplemental Security Income or SSI-Related Medicaid Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2100.4 Individual Who Receives Other Types of Medicaid Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2120 Inability to Contact the Individual Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2130 Declining Medically Dependent Children Program Services Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2210 Income and Resource Verifications for Medicaid Eligibility Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2210.1 Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2300 Interest List Release Closures Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2410.1 Non-STAR Kids Individuals Residing in a Nursing Facility Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2427.1 PSU Procedures for an Individual Approved for a Limited NF Stay without Medicaid (Including an Individual Enrolled in CHIP) Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
2427.2 PSU Procedures for an Individual Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
3100.1 Medical Necessity Adds a section to include TAC requirements for medical necessity.
3420 Transfer from Another Medicaid Waiver Program to Medically Dependent Children Program Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
3430 Transfer from MDCP to Another Medicaid Waiver Program Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
3511 Twelve Months Prior to the Member’s 21st Birthday Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
3520 Transition Policy for Non-Waiver Individuals and Applicants Receiving PCS or CFC Only Removes the requirement for PSU staff to mail provider directories. Also, updates enrollment packet contents and adds related policy updates.
Appendix IV MDCP Frequently Asked Questions Removes the requirement for PSU staff to mail provider directories, consolidates existing language and adds related policy updates.
Appendix VI STAR Kids Transition Activities Removes the requirement for PSU staff to mail provider directories.
Appendix XVIII STAR Kids HEART Naming Conventions Removes references to Form 2604 in the Transition to Adult Programs (MDCP Age-Out) section.
Appendix XIV State Cutoff Dates Adds 2022 cutoff dates.

21-9, New Appendix XVII

Revision Notice 21-9; Effective September 16, 2021

The following change(s) were made:

Section Title Change
Appendix XVII MDCP Eligibility TAC for All Denials and Terminations Provides content in English and Spanish taken from 1 Texas Administrative Code Section 353.1155.