STAR+PLUS Program Support Unit Operational Procedures Handbook

1100, STAR+PLUS Program Overview

Revision 19-13; Effective November 5, 2019

The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system to combine acute care with long term services and supports (LTSS). The STAR+PLUS program does not change Medicaid eligibility or services. It does change the way Medicaid services are delivered.

The STAR+PLUS program combines acute care and LTSS, such as assisting in a member's home with activities of daily living (ADLs), minor home modifications (MHM), respite care (short-term supervision) and personal assistance services (PAS). These services are delivered through providers contracted with managed care organizations (MCOs).

The STAR+PLUS program provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid members.

Service coordination, available to all members, is the main feature of the STAR+PLUS program. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members and providers can work together to help members get acute care, LTSS, Medicare services for dually-eligible members and other community support services.

The STAR+PLUS Home and Community Based Services (HCBS) program is a program approved for the managed care delivery system, designed to allow individuals who qualify for nursing facility (NF) care to receive LTSS to be able to live in the community.

Elements of the STAR+PLUS system are different from traditional service delivery. See the Glossary for the definition of terms specific to the STAR+PLUS HCBS program. For a dictionary of acronyms used in the STAR+PLUS HCBS Program, refer to Appendix VII, Acronyms.

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

The STAR+PLUS Handbook (SPH) includes policies and procedures to be used by MCOs, contractors and service providers in the delivery of STAR+PLUS HCBS program services to eligible members.

1110 Legal Basis

Revision 19-13; Effective November 5, 2019

Statutory basis for the STAR+PLUS program:

  • Title 1 Texas Administrative Code (TAC), §353.601-607 and §353.1153; and
  • Title 4 Government Code, Executive Branch, Subtitle I, Health and Human Services, Chapter 533, Medicaid Managed Care Program.

1120 Values

Revision 18-0; Effective September 4, 2018

The principles and practices that form the foundation for the STAR+PLUS Home and Community Based Services (HCBS) program are based on the following values:

  • Members receive services based on their choices and ongoing assessment of their medical and functional needs.
  • The service delivery system is accessible to the member, responsive to his or her needs and preferences, and flexible in honoring choices regarding living arrangement, services and mode of service delivery.
  • Members use available family, community and third-party services and resources, as well as those provided through the STAR+PLUS HCBS program to meet their needs and identified goals.
  • Services provided to the member must provide safe, cost-effective, and medically or functionally necessary alternatives to nursing facility (NF) placement that allow the member the opportunity to use and maintain family and community contacts and services.
  • The individual service plan (ISP) reflects the member's active participation in the assessment and planning process and his or her responsibility to provide as much self-care as possible.
  • Services must support the member's efforts to retain or regain as much independence as possible in the activities of daily living (ADLs), living arrangement and other areas of personal choice, and in meeting any goals.
  • Individuals and members are provided the education, support and services needed to support the member's efforts to remain in or return to the community.
  • Within the constraints imposed by the cost limit on a member's ISP, the program promotes the member's active involvement and choices regarding the services provided.

1130 Mission Statement

Revision 19-13; Effective November 5, 2019

The mission of Texas Health and Human Services Commission (HHSC) is to provide individually appropriate Medicaid managed care services to adults 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+PLUS 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;
  • foster program innovation; and
  • achieve cost efficiency and cost containment.

1140 STAR+PLUS HCBS Program

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program is a home and community based services program authorized under 1915(c) of the Social Security Act. The STAR+PLUS HCBS program provides respite care, minor home modifications (MHMs), adaptive aids, Transition Assistance Services (TAS), employment assistance (EA), supported employment (SE) and financial management services (FMS) through a STAR+PLUS managed care organization (MCO). This section provides an overview of the STAR+PLUS HCBS program, including its eligibility requirements.

1150 STAR+PLUS HCBS Program Goal

Revision 19-13; Effective November 5, 2019

The goal of the STAR+PLUS Home and Community Based Services (HCBS) program is to support and encourage de-institutionalization of adults age 21 years or older who reside in nursing facilities (NFs).

The STAR+PLUS HCBS program accomplishes this goal by:

  • enabling adults who are to remain safely in their homes and/or community;
  • offering cost-effective alternatives to placement in NFs; and
  • supporting families in the role as the primary caregiver.

1200, STAR+PLUS Program Eligibility

Revision 19-13; Effective November 5, 2019

An individual becomes eligible to be assessed for STAR+PLUS Home and Community Based Services (HCBS) program services when their name reaches the top of the STAR+PLUS HCBS program 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+PLUS. For medical assistance only (MAO) individuals, once their name reaches the top of the interest list, the individual selects an MCO who begins the STAR+PLUS HCBS program eligibility determination process. For individuals currently receiving Medicaid and who are already enrolled with an MCO, they may be able to bypass the interest list through the upgrade process.

A person going through the application and eligibility process for the STAR+PLUS HCBS program is referred to as an applicant once Form H1200, Application for Assistance – Your Texas Benefits, is received by Program Support Unit (PSU) staff or the MCO has crossed the threshold into the person’s home to conduct the Medical Necessity and Level of Care (MN/LOC) Assessment. A person enrolled in STAR+PLUS is referred to as a member. A person who is not an applicant or a member is referred to as an individual.

The STAR+PLUS HCBS program is provided by 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 the STAR+PLUS HCBS program, the applicant or member must meet the following criteria:

  • be 21 years or older;
  • have full Medicaid financial eligibility;
  • be a U.S. citizen;
  • be a resident of Texas;
  • 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 STAR+PLUS HCBS program service; and
  • be living in an appropriate living situation.

Title 1 Texas Administrative Code (TAC) §353.1153(a)(1)(F) states STAR+PLUS HCBS program members cannot be enrolled in more than one Medicaid waiver program at the same time. Refer to Appendix XVIII, Mutually Exclusive Services, to determine if two services may be received simultaneously by an applicant or member.

1210 Age

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(A), STAR+PLUS Home and Community Based Services (HCBS) Program, states an applicant or member must be age 21 or older to be eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff verify the applicant’s age in the Texas Integrated Eligibility Redesign System (TIERS) upon initial entry into the STAR+PLUS HCBS program.

1220 Medicaid Financial Eligibility

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(G) states an applicant or member must be determined financially eligible for Medicaid to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must determine if an applicant or member is eligible for Medicaid by checking the Texas Integrated Eligibility Redesign System (TIERS).

For individuals who do not have Medicaid eligibility, PSU staff must mail Form H1200, Application for Assistance – Your Texas Benefits, to the individual. Once Form H1200 is received back from the applicant, PSU staff must fax Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for a Medicaid eligibility determination. The MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the applicant is eligible for Medicaid.

Individuals who do not have Medicaid eligibility may have Form H1200 on file with the Texas Health and Human Services Commission (HHSC). These individuals may not need to complete a new Form H1200, if Form H1200 was received by HHSC within 90 days. PSU staff must encourage the individual to submit a new Form H1200 if there have been changes in the individual’s financial situation since the last submission of Form H1200. If the individual states there is a current Form H1200 on file with HHSC, PSU staff must verify by faxing Form H1746-A to the MEPD specialist. The MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the individual has a current Form H1200 on file. If the individual has a current Form H1200 on file, the MEPD specialist will also inform PSU staff if the applicant is eligible for Medicaid.

For individuals who have Medicaid eligibility, PSU staff must refer to Appendix V, Medicaid Program Actions, to determine if:

  • Form H1200 must be mailed to the individual;
  • Form H1746-A must be faxed to the MEPD specialist; or
  • no action is required.

If Form H1200 was required to be mailed to the individual, PSU staff must wait for the individual to complete and send Form H1200 back to PSU staff. Once PSU staff receive Form H1200, PSU staff must fax Form H1746-A and Form H1200 to the MEPD specialist. The MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the applicant is eligible for Medicaid.

If only Form H1746-A is required to be sent by PSU staff, the MEPD specialist will respond using the MEPD Communication Tool to inform PSU staff if the individual is eligible for Medicaid.

1230 U.S. Citizenship

Revision 19-13; Effective November 5, 2019

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 a Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Verification of citizenship and identity for eligibility purposes is a one-time activity conducted by an MEPD specialist, as documented in the MEPD HandbookChapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by an MEPD specialist, 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 in those programs.

1240 Texas Residency

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(B), STAR+PLUS Home and Community Based Services (HCBS) Program, states the applicant or member must be a Texas resident to be eligible for the STAR+PLUS HCBS program. Upon initial entry into the STAR+PLUS HCBS program, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist will verify Texas residency. Upon annual assessment, the managed care organization (MCO) verifies ongoing Texas residency.

1250 Medical Necessity Determination

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(a)(1)(C), STAR+PLUS Home and Community Based Services (HCBS) Program, states the applicant or member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) to be eligible for the STAR+PLUS HCBS program.

For STAR+PLUS HCBS program applicants not residing in a nursing facility (NF), the managed care organization (MCO) service coordinator completes and submits the Medical Necessity and Level of Care (MN/LOC) Assessment electronically through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) after obtaining a physician signature.

For STAR+PLUS HCBS program applicants currently residing in an NF and STAR+PLUS HCBS program members at reassessment, the MCO service coordinator completes and submits the MN/LOC Assessment electronically through the TMHP LTCOP. The MCO is not required to obtain a physician signature for STAR+PLUS HCBS program applicants currently residing in an NF and STAR+PLUS HCBS program member reassessment.

Once the MN/LOC Assessment is submitted by the MCO, TMHP staff will review the MN/LOC Assessment to determine if the applicant or member has an MN for an NF LOC.

TMHP staff will also calculate a Resource Utilization Group (RUG) associated with the MN. A RUG is a measure of NF staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for applicants or members and establish the individual service plan (ISP) cost limit. The MCO must retain the MN/LOC Assessment and the physician’s signature, if applicable, in the MCO’s member case file.

1260 Individual Service Plan Cost Limit

Revision 19-13; Effective November 5, 2019

Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, §353.1153(c)(1)(H), STAR+PLUS Home and Community Based Services (HCBS) Program, states the cost of STAR+PLUS HCBS program services on the individual service plan (ISP) should not exceed 202 percent of the cost of care Texas Health and Human Services Commission (HHSC) would pay if the individual was served in a nursing facility (NF). The applicant's or member’s ISP cost limit is calculated by Texas Medicaid & Healthcare Partnership (TMHP) based on information the managed care organization (MCO) service coordinator gathered through the Medical Necessity and Level of Care (MN/LOC) Assessment. The ISP cost limit is represented as a three-digit alphanumeric Resource Utilization Group (RUG). A RUG is a measure of NF staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for applicants or members.

For initial eligibility, the MCO service coordinator must develop an ISP consisting of STAR+PLUS HCBS program services requested by the applicant and the cost of those services. The cost should be developed at or below 202 percent of the cost to provide services to the applicant, based on the RUG in an NF. If the cost exceeds 202 percent, HHSC staff must review the circumstances and, when approved, provide funds through general revenue (GR).

Applicants exceeding the cost limit who are not approved for GR funds cannot elect to receive reduced services for entry to the STAR+PLUS HCBS program if Medicaid state plan services and STAR+PLUS HCBS program services would pose a risk to the individual’s health, safety or welfare.

1270 Unmet Need for at Least One STAR+PLUS HCBS Program Service

Revision 19-13; Effective November 5, 2019

Title 42 Code of Federal Regulations (CFR) §441.302(c) and Title 1 Texas Administrative Code (TAC) §353.1153(a)(1)(D) states individuals must have a need for at least one STAR+PLUS Home and Community Based Services (HCBS) program service to be eligible for the STAR+PLUS HCBS program. For initial and continued eligibility for the STAR+PLUS HCBS program, a member must have an unmet need for support in the community, and therefore use at least one STAR+PLUS HCBS program service during the individual service plan (ISP) year. Therefore, a STAR+PLUS HCBS program ISP which has $0.00 as the “Total Est. Waiver Cost” in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) will be rejected by Program Support Unit (PSU) staff. Members who do not use at least one STAR+PLUS HCBS program service per ISP year are subject to disenrollment from the STAR+PLUS HCBS program. For medical assistance only (MAO) Medicaid members, disenrollment from the STAR+PLUS HCBS program may result in a loss of Medicaid eligibility.

MAO Medicaid members receiving Community First Choice (CFC) services through a 1915(c) Medicaid waiver program must meet eligibility requirements stated in Title 42 CFR §441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all STAR+PLUS HCBS program requirements and must receive one STAR+PLUS HCBS program service per month. Managed care organization (MCO) service coordinators are responsible for tracking monthly services and notifying PSU staff if an MAO member with CFC services is not receiving the minimum requirement of one service per month.

1280 Appropriate Living Arrangement

Revision 19-13; Effective November 5, 2019

Title 42 Code of Federal Regulations (CFR) §441.301(b)(1)(ii) states applicants or members enrolled in the STAR+PLUS Home and Community Based (HCBS) program must not be an inpatient of a hospital, nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID). Non-state group homes are ICF/IID.

Applicants or members who are incarcerated may or may not be able to maintain STAR+PLUS Home and Community Based Services (HCBS) program enrollment. Program Support Unit (PSU) staff must not deny an applicant or member due to incarceration. PSU staff must wait until the applicant or member loses Medicaid eligibility and deny them due to loss of Medicaid eligibility.

1300, STAR+PLUS Services and Service Delivery Options

Revision 19-13; Effective November 5, 2019

Individuals enrolled in the STAR+PLUS program may select a service delivery model for personal assistance services (PAS) or Community First Choice (CFC) services identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H6516, Community First Choice Assessment, and Form H2060-A, Addendum to Form H2060. Individuals receiving STAR+PLUS Home and Community Based Services (HCBS) program services may reside alone, with family members or others at locations of their choice in the community, including adult foster care (AFC) homes or licensed assisted living facilities (ALFs).

The STAR+PLUS HCBS program provides individuals with an array of services necessary to allow the individual to remain in, or return to, a community setting. Providers contracted with managed care organizations (MCOs) provide STAR+PLUS HCBS program services identified on the individual service plan (ISP). The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists to determine financial eligibility for individuals not eligible for Supplemental Security Income (SSI). SSI eligible individuals are Medicaid eligible and can obtain STAR+PLUS HCBS program services without additional financial screening. Refer to Section 3110, Medicaid, Medicare and Dual-Eligibles, for additional information.

STAR+PLUS members choose to participate in the agency option (AO), consumer directed services (CDS) option or service responsibility option (SRO) delivery models.

  • Members who choose the AO model work with the MCO to coordinate service delivery for each service in the ISP.
  • Members who choose the CDS model are given the authority to self-direct designated services. The MCO coordinates delivery of non-member-directed designated services if the member chooses to self-direct designated services. In the CDS model, providers employed by the member or authorized representative (AR) must be qualified personnel to provide authorized services when services are necessary. These personnel may be employed directly by, or through, personal service agreements or subcontracts with the providers. A member's services and service providers must be based on an MCO assessment of the member’s individual needs. Refer to the STAR+PLUS Handbook (SPH)Appendix XXVIII, CDS Training for Service Coordinators and CDS Training Manual, for additional information.
  • In the SRO model, the provider is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The provider also orients attendants to provider policies and standards before sending them to members' homes. The member or designated representative (DR) 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.

Refer to SPH section 8000, Service Delivery Options, for additional information.

1310 Program Services

Revision 19-13; Effective November 5, 2019

1311 Services Available Under STAR+PLUS

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) will assess the member and develop an appropriate individual service plan (ISP) when the service coordinator identifies a need or the member requests additional services. Since MCOs are at risk for paying for a range of acute care and long-term services and supports (LTSS), there is an incentive to provide innovative, cost effective care from the onset in order to prevent or delay the need for more costly institutionalization.

STAR+PLUS members who do not have Medicare are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals can choose a specialist to be their PCP and they receive all services, both acute care and LTSS, from the MCO.

Members who receive both Medicaid and Medicare (dual-eligible) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. The STAR+PLUS program does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

The STAR+PLUS program serves as an insurance policy if members have a need for LTSS at a future time. Refer to section 3110, Medicaid, Medicare and Dual-Eligible, for additional information on dual-eligible coverage.

Medicaid-only members (those who do not receive Medicare) receive traditional Medicaid acute care services plus an annual check-up. For these members, the cost of acute care services is included in the capitation payment to the MCO. For dual-eligible members, the MCO’s capitation payment does not include the cost of acute care.

1312 Long Term Services and Supports

Revision 19-13; Effective November 5, 2019

Day Activity and Health Services (DAHS) and personal attendant services (PAS) are available to STAR+PLUS members who meet functional eligibility requirements. Community First Choice (CFC) services are available to STAR+PLUS members who meet an institutional level of care (LOC), meet functional eligibility requirements, and who receive Supplemental Security Income (SSI) or receive SSI-related Medicaid. Additional services are available under the STAR+PLUS Home and Community Based Services (HCBS) program. For a complete list of services provided under the STAR+PLUS program, refer to the managed care contracts governing the STAR+PLUS program at https://hhs.texas.gov/services/health/provider-information/managed-care-contracts-manuals.

1320 Services Available to STAR+PLUS Members

Revision 19-13; Effective November 5, 2019

STAR+PLUS program members have access to medically and functionally necessary services available in the Medicaid state plan. Some members are eligible for additional services available in the STAR+PLUS Home and Community Based Services (HCBS) program, in addition to their traditional Medicaid state plan STAR+PLUS services.

The Texas Health and Human Services Commission (HHSC) contracts with Medicaid managed care organizations (MCOs) for the provision of STAR+PLUS services. These Medicaid MCOs are responsible for providing a benefit package to members that include all medically-necessary services covered under the traditional, fee-for-service (FFS) Medicaid programs, except for non-capitated services provided to Medicaid members outside of the MCO capitation and listed in each managed care contract. (For example, Attachment B-1, Section 8.2.2.8, of the Uniform Managed Care Contract (UMCC).

STAR+PLUS members also receive enhanced benefits compared to the traditional FFS Medicaid coverage:

  • waiver of the three-prescription per month limit for members not covered by Medicare; and
  • waiver of spell illness limitation for members admitted to a facility as a result of the serious and persistent mental illness (SPMI).

Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for members and prescription drugs. STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual (TMPPM) and the Texas Medicaid Bulletin postings for a more inclusive listing of limitations and exclusions that apply to each Medicaid benefit category. (These documents can be accessed online at: www.tmhp.com.)

The services listed in the managed care contracts (for example, UMCC) are subject to modification based on federal and state laws and regulations and program policy updates.

1330 Acute Care Services Included Under the MCO Capitation Payment

Revision 19-13; Effective November 5, 2019

Services included under the managed care organization (MCO) capitation payment include:

  • ambulance services;
  • audiology services, including hearing aids;
  • behavioral health services, including:
    • inpatient mental health services;
    • outpatient mental health services;
    • outpatient chemical dependency services;
    • mental health rehabilitation for non-duals;
    • mental health targeted case management for non-duals;
    • detoxification services;
    • psychiatry services; and
    • counseling services;
  • birthing services provided by a certified nurse midwife in a birthing center;
  • chiropractic services;
  • dialysis;
  • durable medical equipment (DME) and supplies;
  • Emergency Response Services (ERS);
  • family planning services;
  • home health care services for acute conditions;
  • hospital services;
  • laboratory;
  • long-term services and supports (LTSS) (Refer to section 1340, Long Term Services and Support Listing, below);
  • medical checkups and Comprehensive Care Program (CCP) services for Medicaid for Breast and Cervical Cancer (MBCC) members under age 21;
  • oncology services;
  • optometry, glasses and contact lenses, if medically necessary;
  • podiatry;
  • prenatal care;
  • prescription drugs;
  • primary care services (PCS);
  • preventive services including an annual adult well check;
  • radiology, imaging and X-rays;
  • specialty physician services;
  • therapies, including physical, occupational and speech for acute conditions;
  • transplantation of organs and tissues; and
  • vision services.

1340 Long Term Services and Support Listing

Revision 19-13; Effective November 5, 2019

The following is a non-exhaustive, high-level listing of community-based long-term services and supports (LTSS) included under the STAR+PLUS program:

  • Community First Choice (CFC) - Available to all Medicaid-eligible members (except for members who are considered medical assistance only (MAO) who meet an institutional level of care (LOC) for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) or psychiatric hospital (also called an institution for mental disease). CFC services are provided in a community-based setting. Community-based settings do not include:
    • hospitals;
    • NFs;
    • institutions for mental disease (IMD);
    • ICF/IID; and
    • any setting with the characteristics of an institution.
  • CFC services include:
    • Emergency Response Services (ERS), which are backup systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports;
    • habilitation services, which provide acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
    • personal assistance services (PAS), which help with ADLs, IADLs and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks; and
    • support management, which is training provided to members or authorized representatives (ARs) on how to manage and dismiss their attendants.
  • Day Activity and Health Services (DAHS) — All members of a STAR+PLUS managed care organization (MCO) may receive medically and functionally necessary DAHS. DAHS includes nursing and PAS, therapy extension services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed by the state.
  • Nursing facilities (NFs) — Institutional care to a member whose physician has certified that the member has a medical condition that requires 24-hour nursing care that meets medical necessity (MN) requirements. The need for custodial care solely does not constitute MN for an NF placement. Institutional care includes coverage for the medical, social and psychological needs of each resident, including room and board (R&B) charges, social services, medications not covered by Medicare Part B or D, medical supplies and equipment, rehabilitative services and personal needs items.
  • PAS, formerly known as Primary Home Care (PHC) PAS — All members may receive medically and functionally necessary PAS. PAS includes assisting the member with the performance of ADLs and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the member's need and the plan of care (POC). To be eligible for Medicaid state plan PAS, the MCO must assess applicants in a face-to-face visit. Members are assessed using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment. To be eligible for PAS through programs other than CFC or the STAR+PLUS Home and Community Based Services (HCBS) program, members must score at least 24 on Form H2060. PAS includes three service delivery options:
    • Agency Option (AO);
    • Consumer Directed Services Option (CDS); and
    • Service Responsibility Option (SRO).
  • STAR+PLUS HCBS program — This is for those members who qualify for such services. The state also provides an enriched array of services to members who would otherwise qualify for NF care through the STAR+PLUS HCBS program. The MCO must also provide medically necessary services that are available to members who meet the functional and financial eligibility for the STAR+PLUS HCBS program.

1350 Services Available to STAR+PLUS HCBS Program Members

Revision 19-13; Effective November 5, 2019

Services necessary for the member to remain in or return to the community are identified from the array of services available through the STAR+PLUS Home and Community Based Services (HCBS) program. STAR+PLUS HCBS program services include:

  • Adaptive aids and medical supplies;
  • Adult foster care (AFC);
  • Assisted living (AL) services;
  • Cognitive rehabilitation therapy (CRT);
  • Dental services;
  • Emergency Response Services (ERS);
  • Employment Assistance (EA) services;
  • Financial Management Services (FMS);
  • Home-delivered meals (HDM);
  • Minor home modifications (MHMs);
  • Nursing services;
  • Occupational therapy (OT) services;
  • Personal assistance services (PAS);
  • Physical therapy (PT) services;
  • Respite care services;
  • Speech therapy (ST) services;
  • Supported Employment (SE) services; and
  • Transition Assistance Services (TAS).

1400, MCO Service Coordination

Revision 19-13; Effective November 5, 2019

Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. The MCO service coordinator must contact the member at least once telephonically and at least once face-to-face per year if a member receives long term services and supports (LTSS), has a history of behavioral health issues or substance use disorders (SUD) or is dual eligible. The MCO service coordinator must visit with the member face-to-face at least twice a year if the member receives the STAR+PLUS Home and Community Based Services (HCBS) program or has a complex medical condition. The MCO service coordinator must meet with the member face-to-face at a minimum of four times per year if a member resides in a nursing facility (NF).

All applicants or members of LTSS receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan (ISP) with the individual, family members and provider, as well as authorization of LTSS for the member. MCO service coordination is responsible for working with the applicant or member and his or her acute care and LTSS providers to ensure all of an applicant’s or member's medically and functionally necessary services are provided. This includes referring and assisting the applicant or member in obtaining appointments with specialists, participating in discharge planning for applicants or members in hospitals or the NF, referring members to community organizations for services, and assistance not covered by Medicaid. Service coordination requirements for members receiving the STAR+PLUS HCBS program can be found in Section 3000, STAR+PLUS HCBS Program Eligibility and Services, Section 8000, Specific STAR+PLUS HCBS Program Services, Section 5000, Automation and Payment Issues in STAR+PLUS, and Appendices. Service coordination requirements for members receiving Medicaid state plan LTSS can be found in the Uniform Managed Care Contract (UMCC).

The following sections detail MCO service coordinator responsibilities for applicants or members in certain facilities or programs.

1500, Disclosure of Information

1510 Confidential Nature of Medical Information - HIPAA

Revision 19-13; Effective November 5, 2019

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect 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 individual's date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number and demographic data.

1511 Confidential Nature of a Case Record

Revision 19-13; Effective November 5, 2019
 
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 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.

1512 Custody of Records

Revision 19-13; Effective November 5, 2019

Texas Health and Human Services Commission (HHSC) staff must use reasonable diligence to safeguard, protect and preserve records and prevent disclosure of the information they contain, except as provided by 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.

1520 Responsible Party to Authorize Disclosure

Revision 19-13; Effective November 5, 2019

 

1520.1 Authorized Representative

Revision 19-13; Effective November 5, 2019

Only the member's authorized representative (AR) can exercise the applicant’s or member's rights with respect to protected health information (PHI). Therefore, only an applicant or member's 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 AR if the applicant or member is subjected to domestic violence, abuse or neglect by the AR. Consult the HHSC Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, if it is believed that health information should not be released to the AR.

Note: A responsible party is not automatically an AR.

1520.2 Unemancipated Minors

Revision 19-13; Effective November 5, 2019

A parent is the authorized representative (AR) 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 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.

1520.3 Adults and Emancipated Minors

Revision 19-13; Effective November 5, 2019

The applicant’s or member’s authorized representative (AR) has authority to make health care decisions for the applicant or member if the applicant or member is an adult, emancipated minor or married minor. An AR may be a:

  • person the applicant or 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 the Texas Health and Human Services Commission (HHSC) Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, for approval.

1520.4 Deceased Applicant or Member

Revision 19-13; Effective November 5, 2019

The 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 the Texas Health and Human Services Commission (HHSC) Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, about whether a particular person is the AR of an applicant or member.

1521 Verifying the Identity of an Applicant, Member, Authorized Representative or Third-Party Individual

Revision 19-13; Effective November 5, 2019

 

1521.1 Phone Communication

Revision 23-3; Effective Aug. 21, 2023

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

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

PSU staff must verify that the person who self-identifies as an AR over the phone is listed as the AR in:

  • the Texas Integrated Eligibility Redesign System (TIERS);
  • the most recent signed Form H1200, Application for Assistance – Your Texas Benefits; or 
  • Form H1826, Case Information Release, completed and signed by the individual, applicant or member.  

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

Refer to Section 1530, Information That May Be Disclosed, for more information about scenarios when: 

  • PSU staff is not able to verify the person calling;
  • the person calling PSU staff is not the individual, applicant, member or AR; or 
  • PSU staff must obtain Form 1826.

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

1521.2 In-Person Communication

Revision 19-13; Effective November 5, 2019

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

  • 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 ID card containing the 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, research staff 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 protected health information (PHI) through one of the following:

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

Program Support Unit (PSU) staff must contact the HHSC Office of Chief Counsel staff when other HHSC or MCO staff, federal agency staff, research staff or contractors come to the office without prior notification or inadequate identification and request permission to access records.

1521.3 Electronic Mail Communication

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must respond to electronic mail, also known as email, from an applicant, member, authorized representative (AR) or a third party that contains protected health information (PHI) by 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 by mail or fax.

PSU staff must not send PHI by email to non-government entity individuals, including applicants, members, ARs or third-party individuals. Refer to Section 1531, Verification and Documentation of Disclosure, for approved methods of transmitting PHI to applicants, members, ARs and third-party individuals to whom the applicant, member 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."

PSU staff must include the first three letters of the applicant’s or member’s first and last name in the subject line of emails for case-specific communications. For example, an email subject line for an applicant named John Smith would include “JOH.SMI.” in the email’s subject line.

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

1530 Information That May Be Disclosed

Revision Notice 23-3; Effective Aug. 21, 2023

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

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

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

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

PSU staff must only disclose case-related information with a person verified by the methods described in Section 1521.1, Phone  Communication, Section 1521.2, In-Person Communication, and Section 1521.3, Electronic Mail Communication, when:

  • the Texas Integrated Eligibility Redesign System (TIERS) indicates that the person requesting the information is the AR; 
  • a signed Form H1200, Application for Assistance – Your Texas Benefits, indicates the person requesting the information is the AR; or
  • a valid Form H1826, Case Information Release, is on file or received;
  • the person is HHSC staff including the Medicaid for the Elderly and People with Disabilities (MEPD) specialist; or
  • the person is an HHSC contractor, such as managed care organization (MCO), or the Texas Medicaid & Healthcare Partnership (TMHP) staff.

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

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

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

PSU staff may use the following: 

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

A valid Form H1826 is:

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

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

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

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

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

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

PSU staff must notify a person who requests copies of an individual, applicant, or member’s records maintained by HHSC to email the HHSC Open Records Coordinator mailbox.

PSU staff may refer to Title 20 CFR Section 401-403 for more information about the disclosure of PHI.

1531 Verification and Documentation of Disclosure

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff may only disclose protected health information (PHI) to the applicant, member, authorized representative (AR) or a third-party individual if written consent is provided.

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

  • U.S. passport;
  • Texas Department of Public Safety (DPS) ID card;
  • DPS driver license;
  • DPS Texas Education Identification Certificate;
  • DPS handgun license;
  • U.S. military ID 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 stubs.

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 fax or by mail.

1532 Communication with the Applicant or Member

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant’s, member’s or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member 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.

1533 Confidential Information on Notifications

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member 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 the member’s income of $2,892 exceeds the eligibility limit of $2,313. 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 $2,313.” The comment should simply state, “You are no longer eligible for Medicaid.”
  • Another applicant is being denied STAR+PLUS Home and Community Based Services (HCBS) program services because the presence of weapons in the member’s 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’s or member’s income or the condition of the home environment is a violation of the member’s 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.

1534 PSU Communication with the MCOs

Revision 19-13; Effective November 5, 2019

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for an applicant’s or member's protected health information (PHI) to be shared only with the selected managed care organization (MCO). Program Support Unit (PSU) staff can securely upload documents with PHI by using TxMedCentral. PSU staff must follow Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, when uploading documents to TxMedCentral. If PSU staff upload a document containing member PHI to the incorrect MCO ISP or SPW folder in TxMedCentral, it must be corrected immediately upon realization an error was made.

PSU staff must send notification of all TxMedCentral upload errors to PSU Operations staff. Include the document identifying information, the name of the folder in which it was erroneously uploaded, the name of the folder into which it should have been uploaded and the time the correction was made.

Example: Uploaded XX_2067_123456789_ABCD_1P.doc in SUPSPW at 8:54 a.m. on December 20. Should have been uploaded to MOLSPW. Corrected at 9:22 a.m. December 20.

1535 Applicant or Member Correction of Information

Revision 19-13; Effective November 5, 2019

An applicant, member or authorized representative (AR) has a right to correct any information the Texas Health and Human Services Commission (HHSC) or the managed care organization (MCO) has about the applicant or member and any other individual on the applicant’s 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 or the MCO can contact the applicant or member.

HHSC or the MCO must add corrected information to the case record when HHSC or the MCO agrees to change protected health information (PHI). The incorrect information remains in the file with a note that the information was amended per the member's request.

Notify the applicant, member or AR in writing within 60 days (using agency letterhead) 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.

HHSC or the MCO must ask the member for permission before sharing with third parties if HHSC or the MCO makes a correction to PHI. The agency will make a reasonable effort to share the correct information with persons who received the incorrect information if they may have relied, or could rely, on the information and if it is to the disadvantage of the member. HHSC staff must contact the HHSC Office of Chief Counsel for a record of disclosure. MCOs must follow HHSC procedures as stated in the Uniform Managed Care Contract (UMCC), Section 11.03, Member Records.

Note: Do not follow above procedures when the accuracy of information provided by a member 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.

1536 Disposal of Records

Revision 19-13; Effective November 5, 2019

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.

1600, Member Rights and Responsibilities

Revision 19-13; Effective November 5, 2019

Member rights and responsibilities are included in the Member Handbook. The required critical elements for member handbooks 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, 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 or AR may refer to the Title 1 Texas Administrative Code (TAC) Part 15, §353 Subchapter C, Member Bill of Rights and Responsibilities, to view the full list of member rights and responsibilities.

1700, Notification Requirements

1710 PSU Staff Notification Requirements for Applicants and Members

Revision 22-1; Effective January 31, 2022

Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member or authorized representative (AR) advising of actions taken regarding STAR+PLUS Home and Community Based Services (HCBS) program eligibility and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent indicating program-level approvals, denials and terminations. Form H2065-D must be completed in plain language that can be understood by the applicant, member or AR, following the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language. PSU staff must mail English and Spanish versions of Form H2065-D to the applicant, member or AR.

Form H2065-D is used to notify interest list release (ILR) and Money Follows the Person (MFP) applicants who are certified as meeting STAR+PLUS HCBS program eligibility. Form H2065-D is also used to notify members of ongoing STAR+PLUS HCBS program eligibility at annual reassessment.

PSU staff must notify the applicant or AR of program eligibility approval using Form H2065-D within two business days of the decision for ILR and upgrade applicants. For MFP applicants, PSU staff must notify the applicant or AR of program eligibility approval using Form H2065-D within one business day of the nursing facility (NF) discharge. For reassessments, PSU staff must notify the member or AR of ongoing program eligibility using Form H2065-D within five business days of the ISP being submitted by the managed care organization (MCO). Form H2065-D also includes information on the member’s room and board (R&B) charges and copayment amounts, if applicable.

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

PSU staff must also provide English and Spanish versions of Form H2065-D to the MCO. PSU staff can generate Form H2065-D manually or through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). PSU staff must upload Form H2065-D to TxMedCentral in the MCOs SPW folder on the case action date, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, if Form H2065-D is generated manually. The MCO will be receive a copy of Form H2065-D through the TMHP LTCOP on the date Form H2065-D is generated if Form H2065-D is generated electronically through the TMHP LTCOP.

1720 PSU Staff Notification Requirements for MCOs

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must use Form H2067-MC, Managed Care Programs Communication, for all communications sent to the managed care organization (MCO). PSU staff upload Form H2067-MC to TxMedCentral in the MCO’s STAR+PLUS folder, following the instruction in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Time frames for PSU staff uploading Form H2067-MC can vary between one and five business days depending on the situation. PSU staff must refer to policy in this handbook for specific time frame direction.

1730 PSU Staff Notification Requirements for Medicaid for the Elderly and People with Disabilities or Texas Works

Revision 19-13; Effective November 5, 2019

Some Program Support Unit (PSU) staff actions are based on decisions related to Medicaid financial eligibility determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist or Texas Works (TW) advisor. PSU staff must coordinate approvals, denials and terminations of STAR+PLUS Home and Community Based Services (HCBS) program eligibility with the MEPD specialist. All PSU staff notifications to the MEPD specialist must be sent by fax and include Form H1746-A, MEPD Referral Cover Sheet. PSU staff must refer to Appendix V, Medicaid Program Actions, to determine if MEPD notification is required. MEPD specialists communicate with PSU staff through the MEPD Communication Tool.

For applicants, PSU staff must fax Form H1746-A and Form H1200, Application for Assistance – Your Texas Benefits, to MEPD, if applicable. For applicants pending a Medicaid eligibility determination, PSU staff must fax Form H1746-A to the MEPD specialist when medical necessity (MN) is determined by Texas Medicaid & Healthcare Partnership (TMHP). Once an applicant is authorized to enter the STAR+PLUS HCBS program, PSU staff must fax Form H1746-A to the MEPD specialist.

For denials and terminations not related to a Medicaid financial denial, PSU staff must fax Form H1746-A to the MEPD specialist.

1740 PSU Staff Notification Requirements for Enrollment Resolution Services Unit

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must notify the Enrollment Resolution Services (ERS) Unit for medical assistance only (MAO) applicants that meet STAR+PLUS Home and Community Based Services (HCBS) program eligibility and do not show a managed care organization (MCO) enrollment in the Texas Integrated Eligibility Redesign System (TIERS). PSU staff must also notify the ERS Unit of MAO members having their STAR+PLUS HCBS program eligibility terminated.

The email to the ERS Unit mailbox must include:

  • a subject line including the type of request with the applicant’s first and last initial;
  • applicant or member name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • eligibility or termination effective date;
  • any other relevant information; and
  • any supporting documentation (e.g., Form H2065-D, Notification of Managed Care Program Services).

1750 PSU Staff Notification Requirements for Managed Care Compliance and Operations Unit

Revision 19-13; Effective November 5, 2019

Program Support Unit (PSU) staff must notify the Managed Care Compliance and Operations (MCCO) Unit staff for managed care organization (MCO) noncompliance or delinquency within two business days.

The email to the MCCO Unit mailbox must include:

  • a brief statement explaining the complaint;
  • applicant or member name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO;
  • individual service plan (ISP) effective dates; and
  • any other relevant information.

1760 MCO Notification Requirements for Applicants and Members

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) is responsible for notifying the applicant, member or authorized representative (AR) when a service is denied, reduced or terminated. This is considered an adverse action and the applicant, member or AR has a right to appeal. Appeal rights of STAR+PLUS Home and Community Based Services (HCBS) program applicants or members are in the Uniform Managed Care Contract (UMCC).

1770 MCO 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 45 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.

1800, PSU Online Database Resources

Revision 19-13; Effective November 5, 2019

The Client Assignment and Registration (CARE) System is an online database used by Program Support Unit (PSU) staff. CARE maintains the enrollment records for the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver programs. PSU staff use CARE to prevent dual enrollment in another Medicaid waiver program.

1820 Community Services Interest List

Revision 19-13; Effective November 5, 2019

Community Services Interest List (CSIL) is an online database used by Interest List Management (ILM) Unit and Program Support Unit (PSU) staff. CSIL maintains an interest list and tracks individuals waiting to receive services for Long Term Services and Supports (LTSS) waiver programs including:

  • Community Living Assistance and Support Services (CLASS);
  • Home and Community-based Services (HCS);
  • Medically Dependent Children Program (MDCP);
  • STAR+PLUS Home and Community Based Services (HCBS) program; and
  • Texas Home Living (TxHmL).

PSU staff use CSIL to verify an individual’s status on the interest list and to prevent dual enrollment in another Medicaid waiver program when an individual is entering the STAR+PLUS HCBS program. PSU staff are required to select the appropriate closure reasons and close the CSIL record when an individual is enrolled in the STAR+PLUS HCBS program.

1830 Health and Human Services Commission Benefits Portal

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) Benefits portal is an online database used by Program Support Unit (PSU) and Fair Hearings Unit staff. The HHSC Benefits portal maintains state fair hearing documentation, forms and case statuses.

PSU staff use the HHSC Benefits portal to:

  • enter and submit state fair hearing requests;
  • upload state fair hearing documentation and forms;
  • view documents and forms uploaded by the hearings officer; and
  • view the outcome of state fair hearing decisions.

1840 Health and Human Services (HHS) Enterprise Administrative Report and Tracking System

Revision 19-13; Effective November 5, 2019

Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) is an online database used by Program Support Unit (PSU) staff. HEART is a repository of current and historic case records for applicants and members.

PSU staff use HEART to:

  • review an individual’s, applicant’s or member’s case history;
  • open new case records;
  • update existing case records;
  • upload forms, documents and screenshots;
  • add narratives of case actions;
  • set due date reminders for case actions;
  • track progress on cases;
  • create relationships between case records; and
  • close case records.

PSU staff must search for an individual, applicant or member when any contact or correspondence is received from, or relating to, an individual, applicant or member to determine if there is already a case record open. PSU must open a new case record if one does not already exist.  

For medical assistance only (MAO) individuals and applicants, the patient control number (PCN) field will initially be completed with the individual’s Social Security number (SSN). Once a Medicaid identification (ID) number is assigned to the applicant, PSU staff must update the PCN field to the Medicaid ID number in HEART.

PSU staff will document every case action in the narrative, including telephone calls, mail dates, fax dates, form receipt dates and any other relevant information in the HEART narrative. The HEART documentation should be completed so that someone with no prior knowledge of the case can follow along in HEART and come to the same case action decision. PSU staff must follow the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions, when uploading documents.

PSU staff must close the HEART case record when there is no further PSU staff action required. Once a HEART case record is closed, PSU staff cannot add notes or documentation. PSU staff must send a request to the PSU supervisor when a HEART case record needs to be reopened.

1850 Service Authorization System Online

Revision 19-13; Effective November 5, 2019

Service Authorization System Online (SASO) is an online database used by Program Support Unit (PSU) staff. SASO is the primary repository of service authorization information for individuals enrolled in the Texas Health and Human Services Commission (HHSC) Long Term Services and Supports (LTSS) waiver programs including:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Medically Dependent Children Program (MDCP); and
  • STAR+PLUS Home and Community Based Services (HCBS) program.

Services must be authorized in SASO before a managed care organization (MCO) can receive payment for services delivered to members.

PSU staff use SASO to prevent dual enrollment in another Medicaid waiver program. PSU staff can also use SASO to determine if an individual received the MDCP program prior to November 1, 2016.

1860 Texas Integrated Eligibility Redesign System

Revision 19-13; Effective November 5, 2019

Texas Integrated Eligibility Redesign System (TIERS) is an online database used by Program Support Unit (PSU) staff. TIERS maintains Medicaid eligibility, age and mailing addresses for individuals, applicants and members. PSU staff use TIERS to verify an individual’s, applicant’s or member’s Medicaid eligibility, age and mailing address, and to prevent dual enrollment in another Medicaid waiver program.

1870 Texas Medicaid & Healthcare Partnership Long Term Care Online Portal

Revision 19-13; Effective November 5, 2019

The Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) is an online database used by Program Support Unit (PSU), managed care organizations (MCOs) and TMHP staff. TMHP LTCOP maintains the medical necessity and level of care (MN/LOC), individual service plan (ISP), cost limit, resource utilization group (RUG) cost limits and unmet needs for applicants and members. PSU staff use the LTCOP to:

  • review an applicant’s or member’s case history;
  • verify the MCO has submitted the MN/LOC and ISP timely;
  • verify the MN/LOC has an approved MN and a RUG under the cost limit;
  • verify the ISP has the correct date range and identifies at least one unmet need;
  • adjust ISP date ranges, if applicable;
  • approve, invalidate and terminate ISPs;
  • add case notes to the narrative history;
  • generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language; and
  • generate reports.

1880 TxMedCentral

Revision 19-13; Effective November 5, 2019

TxMedCentral is a secure online bulletin board used by Program Support Unit (PSU) and managed care organizations (MCOs). TxMedCentral maintains forms and documents uploaded by PSU staff and MCOs. PSU staff and MCOs use TxMedCentral for all communications being sent to between the two parties.

PSU staff must periodically purge documents from TxMedCentral due to the volume of forms and documents being uploaded to TxMedCentral. PSU staff must electronically back up documents from the MCO’s ISP and SPW folder daily to prevent loss of form history. Texas Health and Human Services Commission (HHSC) retention policy requires forms and documents to be maintained for five years.

3100, Ancillary Member Resources

3111 Dual-Eligible Members

Revision 18-0; Effective September 4, 2018

Members who receive both Medicaid and Medicare are called dual-eligible members. Dual eligible members choose a managed care organization (MCO), but are not required to choose a primary care provider (PCP) because dual-eligible members receive acute care from their Medicare providers. STAR+PLUS does not impact Medicare eligibility or services. The STAR+PLUS MCO only provides Medicaid long-term services and supports (LTSS) to dual-eligible members.

STAR+PLUS Medicaid-only members are required to choose an MCO and a PCP in the MCO's network. These members receive all covered services, both acute care and LTSS from the MCO.

MCOs are required to contact all members upon enrollment. If there is a need identified or a request from the member, the MCO will assess the member in developing an appropriate plan of care (POC). MCOs are expected to provide innovative, cost-effective care in order to prevent or delay unnecessary institutionalization.

3112 Medicaid Eligibility

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must verify each applicant's current eligibility for Medicaid through the Texas Integrated Eligibility Redesign System (TIERS). PSU staff initiate the Medicaid financial eligibility determination process if there is no existing acceptable Medicaid coverage.

Refer to Section 3114, Applicants with Medicaid Eligibility, for Medicaid programs appropriate for STAR+PLUS HCBS.

Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200. PSU staff must check with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding the need for a new Form H1200.

Refer to Appendix V, Medicaid Program Actions, to determine if a program transfer by the MEPD specialist will be required. Refer to Section 3230, Financial Eligibility, for additional information regarding financial eligibility.

Note: The completion or signing of an application for an applicant or member does not automatically authorize a person to receive protected health information (PHI) from PSU staff or the managed care organization (MCO) regarding that applicant or member. Refer to Section 2240.1, Authorized Representative, for individuals who may receive or authorize the release of an applicant’s or member's personally identifiable information (PII) or PHI under Health Insurance Portability and Accountability Act (HIPPA) privacy regulations.

3113 Transmittal of Form H1200

Revision 18-0; Effective September 4, 2018

When transmitting Form H1200, Application for Assistance – Your Texas Benefits, Program Support Unit (PSU) staff fax all pages of Form H1200 along with any supporting documentation and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. PSU staff will upload all pages of Form H1200 and Form H1746-A to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) with the applicant's valid signature.

The original Form H1200 must be kept for three years after the HEART case record is denied or closed. PSU staff must also retain a copy of the successful fax transmittal confirmation in the HEART case record. Scanning Form H1200 and sending by electronic mail is prohibited.

3114 Applicants with Medicaid Eligibility

Revision 18-0; Effective September 4, 2018

At the time of the initial intake for the STAR+PLUS HCBS program, Program Support Unit (PSU) staff must obtain information on the applicant's Medicaid and/or financial status. PSU staff must obtain verification of the applicant's current eligibility for an appropriate type Medicaid program from the Medicaid for the Elderly and People with Disabilities (MEPD) specialist or through inquiry in the Texas Integrated Eligibility Redesign System (TIERS).

To be financially eligible for the STAR+PLUS HCBS program, refer to the mandatory population described in Section 3221, STAR+PLUS Mandatory Groups.

An applicant who receives Supplemental Security Income (SSI) is financially eligible for Medicaid and does not require a financial determination; the Social Security Administration (SSA) has already made this determination.

An applicant receiving services through Community Attendant Services (CAS) (TP14) is not automatically eligible for the STAR+PLUS HCBS program.

MEPD specialists must be consulted for these applicants. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200.

3115 Applicants Without Medicaid Eligibility

Revision 22-3; Effective Sept. 27, 2022

Title 42 Code of Federal Regulations (CFR) Section 431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas state plan designates the Texas Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for medical assistance only (MAO) Medicaid cases. The Medicaid for the Elderly and People with Disabilities (MEPD) specialist exclusively determines MAO Medicaid financial eligibility for STAR+PLUS Home and Community Based Services (HCBS) program applicants and members. An individual, applicant or member who does not receive Supplemental Security Income (SSI) may apply for MAO Medicaid.

The individual, applicant or member applies for MAO Medicaid by completing and submitting Form H1200, Application for Assistance – Your Texas Benefits, to the enrollment broker, Program Support Unit (PSU) staff or the MEPD specialist. PSU staff must fax Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist within two business days of an applicant or member submitting Form H1200 to PSU staff.

3116 Monthly Income Below the SSI Standard Payment

Revision 18-0; Effective September 4, 2018

An applicant in the community (with no ineligible spouse) who has income less than the Supplemental Security Income (SSI) federal benefit rate (FBR) must apply for SSI through the Social Security Administration (SSA). The Texas Health and Human Services Commission (HHSC) cannot determine financial eligibility for these individuals except for cases in which the SSI application for disability has been pending more than 90 days and a decision is made by HHSC Disability Determination Unit (DDU) staff.

If there is a question whether the applicant should apply for SSI or medical assistance only (MAO), Program Support Unit (PSU) staff may consult the regional Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

3117 Coordination with the MEPD Specialist

Revision 18-0; Effective September 4, 2018

The Program Support Unit (PSU) staff must inform the applicant or member without pre-existing Medicaid coverage and/or his or her authorized representative (AR) that the Medicaid for the Elderly and People with Disabilities (MEPD) specialist will complete a financial eligibility (Medicaid) determination. PSU staff must encourage the applicant, member or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely fashion.

Any information, including information on third-party insurance, obtained by PSU staff must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program according to regional procedures. For those applicants or members already on an appropriate type of Medicaid program, PSU staff must fax:

An applicant for the STAR+PLUS HCBS program who has medical assistance only (MAO) coverage type Medicaid services may only receive the STAR+PLUS HCBS program after a program transfer to Medicaid waivers is completed by the MEPD specialist. When an applicant or member for the STAR+PLUS HCBS program has MAO coverage type, as indicated in the Texas Integrated Eligibility Redesign System (TIERS), a completed Form H1200 must be sent to the applicant or member. The completed application must be forwarded to the MEPD specialist for processing.

PSU staff must also send an email to MEPD at the HHSC OES MEPD IC mailbox that includes the following information:

  • the applicant’s or member’s name;
  • applicant’s or member’s Medicaid identification (ID) number;
  • individual has MAO coverage-type Medicaid, which will require a program transfer; and
  • name and telephone number of the PSU staff contact.

The MEPD specialist will make the necessary changes to allow the MAO coverage-type Medicaid individual to receive the STAR+PLUS HCBS program.

ID of MAO Coverage-Type Medicaid

PSU staff can check TIERS to determine an applicant’s or member’s coverage type. In TIERS, the coverage type on the Search/Summary screen is displayed with the preface of MAO.

Form H1200 is not required for members receiving Supplemental Security Income (SSI).

Note: If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA.

3117.1 Income and Resource Verifications for MEPD

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 by checking Appendix V, Medicaid Program Actions. PSU staff are not required to obtain a copy of the most recent Form H1200 for an individual or applicant already on an appropriate type of Medicaid program. PSU staff must maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in the Texas Integrated Eligibility Redesign System (TIERS). PSU staff must 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, if applicable. An individual or applicant receiving Supplemental Security Income (SSI) is not required to submit Form H1200.

PSU staff must provide Form H1200 and any additional relevant financial information obtained, including information on third-party insurance, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if received, to prevent the individual or applicant from having to provide the information twice. PSU staff must use Form H1746-A, MEPD Referral Cover Sheet, when communicating with the MEPD specialist. PSU staff must maintain a copy of Form H1746-A fax confirmation page in the applicant’s HEART case record, if applicable.

PSU staff must inform MAO individuals or applicants of the importance of providing all required documents to the MEPD specialist. PSU staff must explain that failure to submit the required documentation to the MEPD specialist could result in a delay or denial of their application or their current services.

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program by faxing:

  • Form H1746-A, noting whether the applicant is pending a Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP) or if the applicant has an approved MN/LOC and ISP;
  • Form H1200, if applicable; and
  • any supporting documents, if applicable.

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

PSU staff must send a second Form H1746-A noting the applicant’s start of care (SOC) for the STAR+PLUS HCBS program if the applicant’s MN/LOC and ISP were pending when the initial Form H1746-A was sent to the MEPD specialist.

3117.2 MAO Applicants Not Previously Certified in TIERS

Revision 18-0; Effective September 4, 2018

A new application is defined as an application for a Medicaid for the Elderly and People with Disabilities (MEPD) household not previously certified in the Texas Integrated Eligibility Redesign System (TIERS).

3117.3 Unsigned Applications

Revision 18-0; Effective September 4, 2018

Unsigned applications received by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are returned to the sender. Program Support Unit (PSU) staff must ensure applications are signed prior to referring to the MEPD specialist; if not, PSU staff are required to obtain signatures when unsigned applications are returned.

The application forms are:

  • Form H1200, Application for Assistance – Your Texas Benefits; and
  • Form H1200-A, Medical Assistance Only (MAO) Recertification.

If the MEPD specialist receives an unsigned application from HHSC with Form H1746-A, MEPD Referral Cover Sheet, the MEPD specialist returns the application to PSU staff with an annotation on the cover form (Form H1746-A) that the application is unsigned and must be signed before PSU staff can establish a file date. Once PSU staff receive an unsigned application from the MEPD specialist, it is the responsibility of PSU staff to coordinate with the applicant or member to obtain a signed application and return it to the MEPD specialist for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to applicants or members.

3117.4 Medicaid Eligibility Decisions Pending Past the Program Due Date

Revision 18-0; Effective September 4, 2018

For most Medicaid for the Elderly and People with Disabilities (MEPD) applications, eligibility decisions are due by the 45th day. However, applications for individuals under the age of 65 may require a 90-day time frame to allow the agency to obtain a disability determination. This applies when the person's age is less than 65 and the person does not receive Retirement, Survivors and Disability Insurance (RSDI), Supplemental Security Income (SSI) or Railroad Retirement (RR). A disability determination by the Texas Health and Human Services Commission (HHSC) is required even if the person has received a Medical Necessity and Level of Care (MN/LOC) Assessment determination under the STAR+PLUS Home and Community Based Services (HCBS) program eligibility component criteria.

For other case actions (for example, program transfers) the MEPD specialist may require time to verify income and resources. This is especially true if the previous case was community-based or included an individual declaration of income or resources. Program Support Unit (PSU) staff will email MEPD at the HHSC OES MEPD IC mailbox, requesting a status update, if the case has been pending more than 45 days.

3117.5 Inquires and Complaints

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff can direct other general inquiries and complaints regarding Medicaid for the Elderly and People with Disabilities (MEPD) applications and programs to the HHSC OES MEPD IC mailbox.

3118 Address Changes for Supplemental Security Income Individuals

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must not send address change requests for Supplemental Security Income (SSI) individuals to the Document Processing Center (DPC). PSU staff must inform the individual or authorized representative (AR) to contact the Social Security Administration (SSA) to request the residence address change. The address change will be reflected in the Texas Integrated Eligibility Redesign System (TIERS) after SSA makes the change.

PSU staff must also send an email to the Enrollment Resolution Services (ERS) mailbox to notify ERS of the request for a change in address.

3120 Other Available Services

Revision 18-0; Effective September 4, 2018

 

3121 Prescription Drugs

Revision 18-0; Effective September 4, 2018

Prescription drugs are not part of the managed care organization's (MCO's) array of services. STAR+PLUS Medicaid-only members continue to have prescriptions filled by any pharmacist participating in the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP). The member will receive unlimited medically necessary prescriptions instead of the traditional three prescriptions per month limit. Drug coverage through VDP is limited to the state's formulary and may not cover all of the prescribed medications required for the individual.

Medicare prescription drug coverage (Medicare Part D) is insurance that covers both brand name and generic prescription drugs at participating pharmacies in the member's service area. Medicare prescription drug coverage provides protection for people who have very high drug costs. Medicare members are eligible for this coverage, regardless of income and resources, health status or current prescription expenses. Members who are eligible for both Medicaid and Medicare (dual-eligible) receive the majority of their drugs through Medicare Part D.

The MCO must inform individuals requesting the STAR+PLUS program of prescription coverage available through the STAR+PLUS program and the Medicare Part D program. The following information regarding the impact of the Medicare Part D program on members must be explained to the applicant:

  • If a member is considered dual-eligible (receiving both Medicare and Medicaid), the member obtains prescriptions first through Medicare Part D or, for certain prescribed drugs excluded from Medicare Part D, through the Medicaid VDP.
  • Drug coverage through Medicare is limited to each drug plan's formulary and may not cover all of the prescribed medications required for the member. Prescriptions not covered by Medicare Part D may be paid by the Medicaid VDP; however, the Medicaid VDP formulary does not cover certain prescription drugs and over-the-counter medications.
  • Members who participate in Medicare Part D are responsible for purchasing any medications and copayments for medications not covered through Medicare Part D or the Medicaid VDP.
  • Members not participating, or those choosing private insurance over Medicare Part D, are also responsible for purchasing medications and copayments for medications not covered by Medicare Part D or the Medicaid VDP.
  • Members eligible for both Medicare and Medicaid can receive assistance with prescription costs through the Low Income Subsidy program. These members pay little or no premiums and no deductibles. Drug copayment amounts could range from $1 to $5.

Federal law prohibits the use of STAR+PLUS program funds for Medicare Part D prescriptions, copayments and costs. STAR+PLUS program funds may not be authorized for prescriptions, copayments and costs if the member is eligible for Medicare Part D and chooses private insurance rather than participation in Medicare Part D. Non-covered medications cannot be billed through the STAR+PLUS program as medical supplies or adaptive aids.

Copayments for prescriptions covered by the Veterans Benefits Administration may be authorized as an adaptive aid through the STAR+PLUS program.

Members who contribute to the cost of their care may be eligible to count Medicare Part D costs as an incurred medical expense if they:

  • reside in the community and have a qualified income trust (QIT); or
  • receive adult foster care (AFC) or assisted living (AL) services.

For a member whose current Medicaid identification (ID) card does not include the statement "can receive more than three prescriptions," pharmacists may verify the STAR+PLUS program eligibility for more than three prescriptions by calling Pharmacy Billing at 800-435-4165.

Pharmacists must check the member's Your Texas Benefits Medicaid card monthly to ensure the member remains eligible for Medicaid.

STAR+PLUS Home and Community Based Services (HCBS) program members who contribute to the cost of their care may be eligible to count Medicare Part D costs as incurred medical expenses. Refer to Section 3123, Incurred Medical Expenses.

3122 Over-the-Counter Drugs

Revision 18-0; Effective September 4, 2018

The STAR+PLUS Home and Community Based Services (HCBS) program does not pay for over-the-counter drugs, with or without a prescription or statement from a physician or health professional. Over-the-counter drugs are generally considered medications that may be sold to a customer without a prescription and do not require the direct supervision of a physician or health professional. Common over-the-counter medications include pain relievers, decongestants, antihistamines, cough medicines, vitamins, minerals and herbal supplements. This list is not all inclusive.

Medications, including over-the-counter drugs, not covered through the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP), Medicare Part D or other third-party resources (TPRs), cannot be paid for by the STAR+PLUS HCBS program. Refer to Section 3121, Prescription Drugs, for additional information.

3123 Incurred Medical Expenses

Revision 18-0; Effective September 4, 2018

Incurred medical expenses (IMEs) are out-of-pocket expenses a medical assistance only (MAO) member can incur for necessary medical services. IMEs include the cost of medically necessary items not covered by Medicaid, such as Medicare Part D premiums.

STAR+PLUS Home and Community Based Services (HCBS) program members who contribute to the cost of their care may be eligible to count Medicare Part D costs (such as premiums, enhanced premiums, prescription drug copayments or deductibles, drugs not covered by Medicare Part D, the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP) and non-formulary drugs) as IMEs, if the member:

  • resides in the community and has a Medicaid copayment as a result of a qualified income trust (QIT); or
  • resides in an adult foster care (AFC) home or assisted living facility.

Members who wish to use IMEs to pay for Medicare Part D costs should report these costs to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist so the costs can be included in the calculation of copayment for the STAR+PLUS HCBS program. The member's statement of Medicare Part D expenses is acceptable. No written documentation is required from the member to support the declaration. The arrangement for payment of the prescriptions is between the member and the pharmacist.

Some drugs are not covered by Medicare Part D, Medicaid or private drug coverage. In order for these non-formulary drugs to be considered as IMEs, a member must request an exception from the Medicare Part D plan for the drugs. The member is expected to use the procedure for requesting an exception, as required by his or her Medicare Part D plan. The member can submit the results of the requested exception directly to the MEPD specialist. If an exception is not requested, the non-formulary drugs are not allowable IMEs and the cost will be the responsibility of the member.

The MEPD specialist applies the IME policy during the certification process to all new members who meet the above criteria. The MEPD specialist also reviews Medicare costs and IMEs once every six months as part of the regular case monitoring, or whenever the member makes a request to update IME costs. The member or his or her authorized representative (AR) may identify and request IMEs by contacting the MEPD specialist.

3124 Medical Transportation Program

Revision 18-0; Effective September 4, 2018

STAR+PLUS Home and Community Based Services (HCBS) program members, as recipients of Medicaid, are eligible to use the Medical Transportation Program (MTP) for Medicaid-covered medical appointments. The MTP is accessed by calling the MTP Support Line at 1-877-633-8747. Day activity and health services (DAHS) providers, adult foster care (AFC) and assisted living facility (ALF) providers are responsible for scheduling transportation for the residents.

The local medical transportation contractors have procedures regarding service area limitations, schedules for traveling to certain areas and requirements on the amount of notice required by STAR+PLUS HCBS program members. The AFC or ALF provider must provide an escort for the member, if necessary.

There may be questions about eligibility for residents who are living in AFC or ALF. In cases of difficulties in scheduling, or questions about eligibility for transportation, residents should contact the managed care organization (MCO) to intercede on the resident’s behalf with the local Medicaid medical transportation system.

3125 STAR+PLUS HCBS Program Members Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018

The STAR+PLUS Home and Community Based Services (HCBS) program is required to provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, Community Care Services Eligibility (CCSE) services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's (MCO’s) service coordinator.

3126 STAR+PLUS Members Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018

Members receiving STAR+PLUS services are potentially eligible to receive a variety of services from the Texas Health and Human Services Commission (HHSC). For specific information, refer to Section 3126.1, Community Care Services Eligibility, below.

3126.1 Community Care Services Eligibility

Revision 18-0; Effective September 4, 2018

If STAR+PLUS members meet program requirements, they are eligible to receive the following Community Care Services Eligibility (CCSE) services:

  • adult foster care (AFC);
  • residential care;
  • Emergency Response Services (ERS);
  • home-delivered meals (HDM); or
  • special services to persons with disabilities.

Members may also be eligible for family care if the managed care organization (MCO) has denied their request for personal attendant services due to the:

  • lack of practitioner's statement of need for the services; or
  • lack of personal care tasks.

STAR+PLUS members may never receive the following services from the Texas Health and Human Services Commission (HHSC):

  • Day Activity and Health Services (DAHS);
  • community attendant services (CAS);
  • primary home care (PHC); or
  • assisted living (AL).

An individual requesting CCSE services should be added to any applicable interest lists at the time of the request, in order to protect the date and time of the request. Prior to processing an application, the CCSE case manager must verify the service array does not include a service equivalent of the Title XX, Community Care Programs, service requested. The CCSE case manager may view the STAR+PLUS Program Health Plan Comparison Charts and value-added services (VAS) on the HHSC website at: https://hhs.texas.gov/services/health/medicaid-and-chip/programs/starplus/comparison-charts.

VAS offered by an MCO are extra services approved by HHSC. VAS will vary by MCO. HHSC staff are not required to wait for appeal decisions from MCOs to process requests for Title XX, Community Care Program services if the service requested is not a VAS on the member’s plan. Once released from the interest list, the CCSE case manager verifies the applicant’s MCO does not offer an equivalent service as a VAS and proceeds with the eligibility determination for the requested Title XX, Community Care Program service.

The member should be asked if he or she has requested the service from the MCO, if the requested service is not a VAS but is part of the MCO's service array. If the answer to that question is:

  • No, the CCSE case manager refers the member to the MCO.
  • Yes, and services were approved, the CCSE case manager refers the member to the MCO to initiate service delivery.
  • Yes, and services were not approved or the member doesn't know if he or she was approved, the CCSE case manager contacts Program Support Unit (PSU) staff. Once PSU staff confirm services were not approved, the application can be processed.
  • Unsure, the CCSE case manager refers the member to PSU staff. PSU staff will contact the MCO to inquire about the request.

Note: Once released from the interest list, CCSE case managers may proceed to determine eligibility. CCSE case managers process applications for individuals who are enrolled in STAR+PLUS services managed care only if the individuals meet the criteria outlined above. Do not authorize Title XX, Community Care Programs, services for anyone receiving the STAR+PLUS Home and Community Based Services (HCBS) program.

3127 Health Insurance Premium Payment Program

Revision 18-0; Effective September 4, 2018

The Health Insurance Premium Payment (HIPP) program is a Medicaid program that reimburses eligible individuals for their share of an employer-sponsored HIPP. The Texas Health and Human Services Commission (HHSC) pays for copayments and deductibles for Medicaid-covered services provided by Medicaid providers. HIPP individuals also can receive Medicaid benefits (provided by a Medicaid-enrolled provider) not covered by their employer-sponsored health insurance.

In order to qualify for HIPP, an employee must either be Medicaid eligible or have a family member who is Medicaid eligible. The reimbursement may pay for individuals and their family members to receive employer-sponsored health insurance benefits when it is determined the cost of insurance premiums and administration are less than the cost of projected Medicaid expenditures.

Individuals who participate in the HIPP program may participate in STAR+PLUS and remain enrolled in HIPP.

3200, Eligibility

Revision 23-2; Effective May 15, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required. 

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

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

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

PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.

Refer to section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.

3210 Service Areas

Revision 18-0; Effective September 4, 2018

STAR+PLUS services are currently available statewide broken down by service areas:

Service AreaCounty
Bexar Service Area:Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties.
Dallas Service Area:Collin, Dallas, Ellis, Hunt, Kaufman, Navarro and Rockwell counties.
Harris Service Area:Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller and Wharton counties.
El Paso Service Area:El Paso and Hudspeth counties.
Hidalgo Service Area:Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy and Zapata counties.
Jefferson Service Area:Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler and Walker counties.
Lubbock Service Area:Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher and Terry counties.
Medicaid Rural Service Area (RSA) Central Texas Service Area (Waco):Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell and Washington counties.
Medicaid RSA Northeast Texas Service Area (Tyler):Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt and Wood counties.
Medicaid RSA West Texas Service Area (Abilene):Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallam, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Yoakum, Young and Zavala counties.
Nueces Service Area:Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kennedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria counties.
Tarrant Service Area:Denton, Hood, Johnson, Parker, Tarrant, and Wise counties.
Travis Service Area:Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties.

3220 Eligible Groups

Revision 18-0; Effective September 4, 2018

3221 STAR+PLUS Mandatory Groups

Revision 18-0; Effective September 4, 2018

The following groups of individuals must receive services through the STAR+PLUS program. The program designations are used in the following list.

  • Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) type of assistance (TA) 01, TA 02 and TA 22 — Individuals age 21 or over who qualify for this needs-tested program administered by the Social Security Administration (SSA) (full Medicaid recipients).
  • Pickle Amendment Group, TIERS type program (TP) 03 — Individuals age 21 or over who would continue to be eligible for SSI benefits if cost of living adjustment (COLAs) increases were deducted from his or her countable income.
  • Disabled Widow(s)/Widower(s), TIERS TP 21 — Widow(s)/widower(s), aged 60-65 and with a disability, who:
    • were denied SSI benefits because of entitlement to early aged widow's or widower's benefits;
    • are ineligible for Medicare; and
    • would continue to be eligible for SSI benefits in the absence of those early aged widow's or widower's benefits and any increases in those benefits.
  • Another group of TIERS TP 22 recipients include Early Widow(s)/Widower(s), aged 50-60 and with a disability, who:
    • are ineligible for Medicare and were denied SSI due to an increase in widow's/widower's benefits as a result of the relaxing of disability criteria; and
    • would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
  • Disabled Adult Children (DAC), TIERS TP 18 — Adults over age 21 with a disability that began before age 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
  • Medicaid Buy-In, TIERS TP 87 (designated in TIERS as "ME — Medicaid Buy In") — Disabled working adults over age 21 who receive full Medicaid benefits as a result of buying into the Medicaid program.
  • Medicaid for Breast and Cervical Cancer (MBCC) recipients, TIERS TA 67 — Individuals aged 18 to the 65th birth month who meet eligibility requirements defined in Texas Administrative Code (TAC), Title 1, Part 15, Chapter 366, Subchapter D.
  • STAR+PLUS Home and Community Based Services (HCBS) program members who are medical assistance only (MAO), TIERS TA 10 (ME-Waiver) — Individuals who are eligible for STAR+PLUS because they participate in the STAR+PLUS HCBS program.  
  • Most nursing facility (NF) residents, TIERS TP 38 or TA06 (SSI) or TP 17 (medical assistance only (MAO)) — Most individuals residing in an NF.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact Program Support Unit (PSU) staff and provide the details for disenrollment from STAR+PLUS.

3222 STAR+PLUS Excluded Groups

Revision 18-0; Effective September 4, 2018

For excluded groups, refer to Texas Administrative Code (TAC), Title 1, Section 353.603, Member Participation.

3223 Hospice Services in STAR+PLUS

Revision 18-0; Effective September 4, 2018

Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of hospice services. Hospice provides services related to terminal illness that are not available under the STAR+PLUS program. For example, hospice providers are able to administer pain control medications that are not available to STAR+PLUS providers.

NF hospice services can be identified in the Service Authorization System Online (SASO) as service group (SG) 8, service code (SC) 31. The NF counter is activated by non-hospice NF authorizations, which appear in SASO as SG1/SC1 or SG1/SC3.

3230 Financial Eligibility

Revision 23-2; Effective May 15, 2023

Title 1 Texas Administrative Code (TAC) Section 353.1153 states that an individual, applicant or member must be financially eligible for Medicaid to receive the STAR+PLUS Home and Community Based Services (HCBS) program. Program Support Unit (PSU) staff must review Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

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

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

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

PSU staff must deny the individual within two business days from the 30th day of the date Form 2606 was mailed for failure to return the signed and completed application needed to determine financial eligibility. PSU staff must check TIERS to ensure Form H1200 was not mailed directly to the MEPD specialist before denying the individual or applicant.

Refer to section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.

3231 Individual with a Qualified Income Trust

Revision 22-3; Effective Sept. 27, 2022

An individual or applicant who has a qualified income trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though his or her income is greater than the special institutional income limit for the program. Income diverted to the trust does not count for the purposes of determining financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. A person or applicant may be eligible for services if all other eligibility criteria are met, even if the amount they have available for copayment equals or exceeds the total cost of their individual service plan (ISP).

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

3232 Payments from the Qualified Income Trust

Revision 23-2; Effective May 15, 2023

An Applicant or member with a qualified income trust (QIT) is responsible for a copayment if they are living in an adult foster care (AFC), assisted living facility (ALF) or home setting. The managed care organization (MCO) must explain to the applicant or member that the funds from the QIT made available for the copayment must be used to purchase STAR+PLUS Home and Community Based Services (HCBS) program services. The member must make payments directly to the AFC, ALF or other service providers. The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determine the copayment amount for members with a QIT. 

PSU staff must document the copayment amount for services other than AFC or ALF using Form H2065-D, Notification of Managed Care Program Services. PSU staff must refer to Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, when generating Form H2065-D. PSU staff must refer to section 3233, Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL, if the available QIT copayment amount is sufficient to pay the AFC or ALF.

The total available QIT copayment amount is not entered on Form H1700-1, Individual Service Plan, and is not reflected in SASO copayment screens for a QIT member that lives at home.

3233 Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL

Revision 18-0; Effective September 4, 2018

If the available qualified income trust (QIT) copayment amount exceeds the daily rate for adult foster care (AFC) or assisted living (AL), the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The member is authorized as AL Apartment. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May).

The managed care organization (MCO) may complete Form 1578, Qualified Income Trust (QIT) Copayment Agreement, each month or complete the copayment amount for several months in the future. If the copayment amount changes for any of the months the member has been notified of in advance, Form 1578 must be sent to reflect the new copayment amounts for each month. The MCO must maintain a copy of each Form 1578 in the member's folder.

If any QIT copayment funds remain after the monthly copayment is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the in-home provider. In these cases, the AFC or AL provider, in-home provider, member and trustee must be notified of the amounts to be collected from the member based on the days in the month.

Example: In the same example above, the member has a $134.60 copayment remaining in the month of April to pay for services delivered by the provider. In May, the member has $92.42 remaining to pay for services delivered by the provider.

Failure to pay the required QIT copayment could result in termination of services. Refer to section 3235, Refusal to Pay Qualified Income Trust Copayment.

3234 Qualified Income Trust Copayment Agreement

Revision 18-0; Effective September 4, 2018

The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

  • service purchased;
  • amount available for copayment;
  • unit rate;
  • units purchased; and
  • monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in adult foster care (AFC) or an assisted living facility (ALF), the copayment amount is first applied to the cost of AFC or ALF. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase nursing, PAS or medical supplies.

Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

3234.1 Calculation Example and Completion of Form 1578

Revision 18-0; Effective September 4, 2018

There are 1,400 units (hours) of personal assistance services (PAS) included in the initial individual service plan (ISP). The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) equals 115.101 units; rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, Qualified Income Trust (QIT) Copayment Agreement, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Calculate the annual amount of units to be purchased through QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through the QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form H1700-1, Individual Service Plan (Pg. 1). For example, 1,400 units minus 1,380 equals 20 units of PAS to be entered on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the managed care organization (MCO) discusses the copayment with the applicant or member and the trustee of the trust. After explaining the requirements, the applicant, member, authorized representative (AR) and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant, member or AR and the trustee.

Services cannot begin until Form 1578 is signed, indicating the applicant or member's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant or member refuses to sign the adjusted ISP or the copayment agreement, services are denied for failure to pay the required copayment.

3235 Refusal to Pay Qualified Income Trust Copayment

Revision 18-0; Effective September 4, 2018

The trustee of the qualified income trust (QIT) must pay the QIT copayment directly to the provider(s) by the 10th day of the month, or not later than 10 days after STAR+PLUS Home and Community Based Services (HCBS) program services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for services, the provider must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, within two business days. The MCO must contact the trustee to learn the reason for refusal to pay. The MCO must also:

  • write a letter to the member and the trustee explaining the consequences of continued failure to pay; and
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the trustee has refused to make the copayment.

If the copayment is not fully paid within 30 days of the due date, the MCO initiates denial.

If the Home and Community Support Services (HCSS) provider does not deliver sufficient services to use the copayment amount, the HCSS provider must refund any remaining copayment to the trustee and notify the member and MCO via Form H2067-MC.

Example: The provider collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the member went out of town. The provider must refund the dollar amount difference between 36.5 hours and 15 hours. The MCO must notify the MEPD specialist of the refund.

Refer to section 7100, Adult Foster Care, for procedures related to failure to pay copayment.

3236 Copayment and Room and Board

Revision 18-0; Effective September 4, 2018

Members who are determined to be financially eligible based on the special medical assistance only (MAO) institutional income limit may be required to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program services. The method for determining the member's copayment is documented on the Medicaid for the Elderly and People with Disabilities (MEPD) copayment worksheet for the STAR+PLUS HCBS program.

The copayment amount is the member's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of services funded through the STAR+PLUS HCBS program and specified on the member's individual service plan (ISP). The copayment must not exceed the cost of services actually delivered. Members must pay the cost-sharing amount directly to the provider contracted to deliver authorized STAR+PLUS HCBS program services.

To determine the room and board (R&B) amounts for members residing in adult foster care (AFC) or assisted living facility (ALF), apply the following post-eligibility calculations:

  • for individuals, the R&B amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance;
  • for SSI couples, the R&B amount is the SSI FBR [for a couple] minus the personal needs allowance for an individual multiplied by two; or
  • for couples with incomes that exceed the SSI FBR for couples, the R&B amount is the couple's income minus the personal needs allowance for an individual multiplied by two. This amount cannot exceed double the R&B amount for an individual.

Some individuals will be responsible for contributing toward the cost of STAR+PLUS HCBS program services. This is referred to as copayment and/or R&B charges. The copayment amount is not a factor in determining the individual's eligibility for services.

The MEPD specialist calculates the copayment and deducts allowable incurred medical expenses (IMEs) for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a qualified income trust (QIT). Refer to section 3123, Incurred Medical Expenses, and Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, of the MEPD Handbook.

SSI recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance (RSDI), are not required to make a copayment and no copayment calculation is necessary for them. STAR+PLUS HCBS program members who reside in AFC or ALF settings may be required to pay a copayment.

The managed care organization (MCO) must clearly explain to the individual, if it is determined the individual must pay a monthly copayment, that the copayment amount must be paid directly to the AFC or ALF provider. All STAR+PLUS HCBS program members, including SSI recipients, are required to pay R&B in an AFC and ALF.

The MCO must also explain to the individual that the individual is required to pay the AFC or ALF provider an R&B charge. If the member fails to pay the agreed-upon R&B charge and/or copayment, the member could be terminated from the STAR+PLUS HCBS program.

Program Support Unit (PSU) staff notify the member and MCO of new copayment amounts to be collected on Form H2065-D, Notification of Managed Care Program Services.

Refer to section 3232, Payments from the Qualified Income Trust, and section 3234, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.

3237 Determining Room and Board Charges

Revision 23-2; Effective May 15, 2023

All STAR+PLUS Home and Community Based Services (HCBS) program members must pay the room and board (R&B) charges to be eligible for an adult foster care (AFC) or assisted living facility (ALF).

The AFC or ALF can negotiate a lower R&B amount with the member, but they cannot waive it. There is no impact to PSU staff processes if there is an agreement for a lower R&B amount between the AFC or ALF and the member. PSU must continue to enter the R&B fixed amount on the Form H2065-D, Notification of Managed Care Program Services.

The member must pay the R&B charges to the AFC or ALF to remain eligible for Medicaid through the STAR+PLUS HCBS program. Refer to section 6400, Disenrollment Request Policy, if a member refuses to pay their R&B charges.

3238 Determining Copayment Amounts

Revision 23-2; Effective May 15, 2023

The Medicaid for the Elderly and People with Disabilities (MEPD) specialist determines the amount of money available for copayment after determining financial eligibility for Medicaid. The copayment amount will leave a personal needs allowance (PNA) of $85 for a single person and $170 for a couple. The MEPD specialist must notify Program Support Unit (PSU) staff of the amount available for the monthly copayment through the MEPD Communication Tool. PSU staff must provide this information to the managed care organization (MCO) by uploading Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

3239 Copayment Changes

Revision Notice 23-4; Effective Dec. 7, 2023

A member's copayment may change during the time he or she is receiving the STAR+PLUS Home and Community Based Services (HCBS) program. Copayment changes are typically due to a change in income, medical expenses or other circumstances.

The Medicaid for the Elderly and People with Disabilities (MEPD) specialists is responsible for calculating copayment amounts. The MEPD specialist notifies Program Support Unit (PSU) staff through the MEPD Communications Tool of copayment amounts or PSU staff may determine the copayment amount has changed in Texas Integrated Eligibility Redesign System (TIERS) at reassessment. The MEPD specialist will inform PSU staff if corrections to the member's copayment are necessary based on a change in the income amount available for copayment.

Copayment changes are always effective on the first day of the month.

PSU staff must complete the following activities within five business days of obtaining the copayment amounts:

  • mail Form H2065-D, Notification of Managed Care Program Services, to the member;
  • upload Form H2065-D to the MCOHub;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

Adverse action is required if the copayment amount is increasing. The copayment increase is effective the first day of the month after the adverse action period has expired.

Adverse action is not required when:

  • the initial Form H2065-D is generated advising the member of the copayment amounts for the first time;
  • no changes are occurring to ongoing copayment amounts; or
  • copayment amounts are decreasing.

The copayment amount is effective the first day of the month following the copayment amount being determined when adverse action is not required.

The MEPD specialist and MCO will handle issues related to underpayments, refunds, and copayment amount appeals.

3240 STAR+PLUS HCBS Program Requirements

Revision 18-0; Effective September 4, 2018

The STAR+PLUS Home and Community Based Services (HCBS) program 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 the STAR+PLUS HCBS program, the following criteria must be met:

  • medical necessity (MN) (Refer to section 3241, Medical Necessity Determination);
  • services under the established cost limits (Refer to section 3242.1, Maximum Limit);
  • the member's unmet need for at least one STAR+PLUS HCBS program service (Refer to section 3242.2, Unmet Need for at Least One STAR+PLUS HCBS Program Service); and
  • approved Medicaid eligibility.

3241 Medical Necessity

Revision 21-10; Effective October 25, 2021

Title 26 Texas Administrative Code (TAC) Section 554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the STAR+PLUS Home and Community Based Services (HCBS) program. 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.

3241.1 Medical Necessity Determination

Revision 21-10; Effective October 25, 2021

A STAR+PLUS Home and Community Based Services (HCBS) program applicant or member must have a valid medical necessity (MN) determination before admission into the STAR+PLUS HCBS program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant or member's individual service plan (ISP) cost limit is calculated based on the MN/LOC Assessment information.

The managed care organization (MCO) completes and submits MN/LOC Assessments to Texas Medicaid & Healthcare Partnership (TMHP) for STAR+PLUS HCBS program applicants or members. The MN/LOC Assessment for applicants requires a physician’s signature attesting the applicant does meet the criteria to reside in a nursing facility (NF) setting. TMHP processes MN/LOC Assessments to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of NF staffing intensity and used in the STAR+PLUS HCBS program to:

  • categorize needs for applicants or members; and
  • establish the ISP cost limit.

The TMHP Long Term Care Online Portal (LTCOP) generates an alphanumeric three-digit RUG value when processing an MN/LOC Assessment, which appears in the Level of Service record in the Service Authorization System Online (SASO). An MN/LOC Assessment with incomplete information results in a “BC1” code instead of a RUG value. An MN/LOC Assessment resulting with a “BC1” code does not have all of the information necessary for TMHP to calculate a RUG value for the applicant or member accurately. Code “BC1” is not a valid RUG value to determine STAR+PLUS HCBS program eligibility.

The MCO must correct the MN/LOC Assessment information within 14 days of submitting the assessment that resulted in a “BC1” code. The MCO must inactivate the MN/LOC Assessment and resubmit the MN/LOC Assessment with correct information to TMHP within 14 days.

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 ISP has been received. PSU staff must indicate the start of care (SOC) for the STAR+PLUS HCBS 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 XXXIII, STAR+PLUS HEART Naming Conventions.

3241.2 Medical Necessity Determination for an Individual or Applicant Residing in an NF

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must research the individual’s or applicant's status in the nursing facility (NF) at initial contact and determine whether the individual or applicant has a current medical necessity (MN). This information helps determine whether the managed care organization (MCO) should complete the Medical Necessity and Level of Care (MN/LOC) Assessment. PSU staff must make every effort to determine if authorizing the MCO to complete the MN/LOC Assessment is necessary, to avoid duplication of submittal to Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for an MN determination.

PSU staff must verify if the NF individual or applicant has an approved MN in the TMHP LTCOP. The MCO must not complete a new MN/LOC Assessment if there is a current and approved MN determination in the TMHP LTCOP.

The NF should complete the Minimum Data Set (MDS) if an individual or applicant is applying for Medicaid as a resident in the NF and is concurrently applying for the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO is not required to complete a new MN/LOC Assessment when there is a current and valid MDS in the TMHP LTCOP. PSU staff must notify the MCO that an MN exists by entering the Resource Utilization Group (RUG) value and expiration date in Section A, Item 6, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, or on Form H2067-MC, Managed Care Programs Communication, if the applicant is already enrolled in an MCO. If the NF refuses to complete the MDS in a timely manner, PSU staff must authorize the MCO to complete the MN/LOC Assessment for the individual or applicant by entering N/A in Section A, Item 6, of Form H3676 and uploading to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

PSU staff must authorize the MCO to complete the MN/LOC Assessment, as described above, when an individual or applicant enters the NF on Medicare and does not have a current and valid MDS in the TMHP LTCOP.

PSU staff must approve STAR+PLUS HCBS program eligibility based on a current and valid NF MDS and RUG value even if there is a previously denied MN determination on the MN/LOC Assessment in the TMHP LTCOP.

PSU staff must verify the following in SASO:

  • an MN record is present on the Medical Necessity Summary page so the individual service plan (ISP) registration does not suspend; and
  • the MN record matches the ISP end date.

PSU staff must adjust the MN/LOC Assessment end date to match the ISP end date on the Medical Necessity Summary page, if applicable.

3241.3 Medical Necessity Determination for Applicants Not Residing in NFs

Revision 21-10; Effective October 25, 2021

Texas Medicaid & Healthcare Partnership (TMHP) must make a determination based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the managed care organization (MCO) for all STAR+PLUS Home and Community Based Services (HCBS) program applicants not living in nursing facilities (NFs).

The MCO must submit the MN/LOC Assessment to the TMHP Long Term Care Online Portal (LTCOP) after obtaining the physician’s signature.

3242 Individual Cost Limit Requirement

Revision 18-0; Effective September 4, 2018

3242.1 Maximum Limit

Revision 18-0; Effective September 4, 2018

The cost of the STAR+PLUS Home and Community Based Services (HCBS) program cannot exceed 202 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the STAR+PLUS HCBS program applicant must have an individual service plan (ISP) developed that is at or below 202 percent of what it would cost to provide services in an NF.

For initial applications, the total cost of services for an applicant's ISP must be equal to or below the individual's ISP cost limit. Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if this would pose a risk to the individual's health, safety and welfare.

3242.2 Unmet Need for at Least One STAR+PLUS HCBS Program Service

Revision 18-0; Effective September 4, 2018

The Code of Federal Regulations (CFR) specifies individuals are not eligible to receive the STAR+PLUS Home and Community Based Services (HCBS) program unless they have a need for at least one STAR+PLUS HCBS program service per individual service plan (ISP) year. Therefore, the Texas Health and Human Services Commission (HHSC) cannot approve any ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form H1700-1, Individual Service Plan (Pg. 1). When Program Support Unit (PSU) staff receive an ISP from the managed care organization (MCO) with a $0.00 STAR+PLUS HCBS program cost, the following activities occur.

Within two business days:

PSU staff upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. This will inform the MCO to verify if the ISP, which has no services, is accurate.

  • If the ISP was submitted incorrectly:
    • the MCO must resubmit a corrected ISP within two business days (for example, the ISP uploaded correctly but is missing services); and
    • PSU staff must honor the original uploaded date if the MCO uploads the corrected ISP within two business days of notification by PSU staff; or
  • If the ISP was submitted correctly:
    • the MCO must upload Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, informing PSU staff the ISP reflects the member's needs; and
    • PSU staff:
      • begin denial procedures for these cases by completing Form H2065-D, Notification of Managed Care Program Services;
      • mail Form H2065-D to the applicant or member;
      • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV;
      • fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable; and
      • email Form H2065-D to the Enrollment Resolution Services (ERS) mailbox.

3300, Administrative Procedures

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff operate in each Texas Health and Human Services Commission (HHSC) STAR+PLUS managed care service area. PSU staff provide support necessary for the coordination of long-term services and supports (LTSS), including the STAR+PLUS Home and Community Based Services (HCBS) program, for members who transfer in and out of STAR+PLUS service areas. PSU staff are also the point of contact for the coordination and monitoring of members transitioning from:

  • nursing facilities (NFs) to the community, and
  • the Medically Dependent Children Program (MDCP) to the STAR+PLUS HCBS program.

Responsibilities of PSU staff include:

  • acting as an intermediary in relaying communications between Community Care Services Eligibility (CCSE) staff and the managed care organization (MCO);
  • receiving requests for services from CCSE staff performing intake tasks;
  • coordinating the application process for the STAR+PLUS HCBS program for NF residents who wish to transition to the community;
  • assisting applicants with enrollment through the Texas Health and Human Services Commission (HHSC) enrollment broker to select an MCO and primary care provider (PCP), if necessary;
  • coordinating with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist regarding Medicaid eligibility, as appropriate;
  • sending service authorizations (Form H3676, Managed Care Pre-Enrollment Assessment Authorization(PDF)) to the MCO to initiate STAR+PLUS HCBS program assessments for applicants;
  • serving as the primary contact for transitions in and out of STAR+PLUS service areas;
  • assisting CCSE case managers in processing applications for non-Medicaid services by verifying the MCO denied the equivalent service under STAR+PLUS (Refer to section 3510, Money Follows the Person and Managed Care);
  • assisting MCO members requesting placement on an interest list for services excluded from managed care (Refer to section 3222, STAR+PLUS Excluded Groups);
  • processing applicants released from the STAR+PLUS HCBS program interest list;
  • assisting members who are aging out of MDCP and/or Texas Health Steps (THSteps) Comprehensive Care Program (CCP) in transferring to the STAR+PLUS HCBS program (Refer to section 3420, Individuals Transitioning Services for Adults);
  • coordinating continuity of care for members suspended or disenrolled from STAR+PLUS;
  • approving the STAR+PLUS HCBS program based upon eligibility;
  • making Service Authorization System Online (SASO) entries, as required for actions involving STAR+PLUS HCBS program members;
  • handling the administrative claims process;
  • researching and requesting disenrollment when the member is enrolled inappropriately;
  • denying eligibility for the STAR+PLUS HCBS program; and
  • handling requests for state fair hearings for applicants or members who are denied STAR+PLUS HCBS program eligibility.

3310 Intake and Enrollment

Revision 18-0; Effective September 4, 2018

When Community Care Services Eligibility (CCSE) staff receive a request for the STAR+PLUS Home and Community Based Services (HCBS) program, CCSE intake staff must assess whether the request for services should be forwarded for processing to the:

  • Intellectual or Developmental Disabilities (IDD) Program Eligibility and Support;
  • Texas Health and Human Services Commission (HHSC) enrollment broker;
  • Program Support Unit (PSU) staff;
  • Interest List Management (ILM) Unit staff; or
  • appropriate managed care organization (MCO).

Use the chart below to determine how to process requests for services in STAR+PLUS.

Type of IndividualEnrolled with a STAR+PLUS MCO?How does CCSE handle this request?
Full Medicaid individual applying for the STAR+PLUS HCBS programNo.

Forward the request to the HHSC enrollment broker. Supplemental Security Income (SSI) or other full Medicaid program individuals never go on the STAR+PLUS HCBS program interest list, whether the individual is enrolled with STAR+PLUS or not.

The HHSC enrollment broker determines what is preventing MCO enrollment and takes action to resolve the issue, which may include referral to the HHSC or contact with the individual.

Full Medicaid individual applying for the STAR+PLUS HCBS programYes.Refer the individual to the MCO for the STAR+PLUS HCBS program. This individual will never go on the interest list.
Medically Dependent Children Program (MDCP) member who is turning age 21No. MDCP is excluded from STAR+PLUS.The MDCP_PDN Transition Report is emailed to the PSU supervisor identifying individuals who are turning age 21 within the next 18 months and who receive MDCP and/or PDN. See the procedures for transition from MDCP to the STAR+PLUS HCBS program in section 3420, Individuals Transitioning Services for Adults. These individuals never go on the interest list.
Medical assistance only (MAO) applicant for the STAR+PLUS HCBS programNo.CCSE staff receiving the request will place the individual on the STAR+PLUS HCBS program interest list.
Nursing facility (NF) resident applying for the STAR+PLUS HCBS programYes.The resident must be referred to the MCO for an upgrade to the STAR+PLUS HCBS program.
NF resident applying for the STAR+PLUS HCBS programNo.All Money Follows the Person (MFP) individuals are placed on the interest list by CCSE intake staff and immediately assigned. The Community Services Interest List (CSIL) database assignment automatically generates an email notifying PSU staff of the referral.

Due to member choice issues, MCOs are prohibited from contacting the applicant without the authorization from PSU staff to complete the required STAR+PLUS HCBS assessments. For MDCP members aging out, individuals on the STAR+PLUS HCBS program interest list, or MFP individuals, PSU staff:

Note: When PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

Note: CCSE intake staff must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the request and referral process when the individual requesting services is determined to be age 55 years or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock.  
CCSE intake staff must be aware of the PACE service areas (SAs) and referral procedures. Additional information on PACE can be found at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/program-all-inclusive-care-elderly-pace.

3311 Interim Services for Individuals Awaiting Managed Care Enrollment

Revision 18-0; Effective September 4, 2018

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care Services Eligibility (CCSE) program. Referrals to CCSE must be made for all active Medicaid individuals awaiting enrollment for managed care. CCSE case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

3311.1 Interest List Procedures

Revision 22-1; Effective January 31, 2022

Interest List Management (ILM) Unit staff are Texas Health and Human Services Commission (HHSC) staff responsible for maintaining and releasing individuals from the STAR+PLUS Home and Community Based Services (HCBS) program interest list. ILM Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the STAR+PLUS HCBS program. ILM Unit staff must release individuals from the STAR+PLUS HCBS program interest list as slots become available in the program.

ILM Unit staff must use the CSIL database to track nursing facility (NF) residents who are not SSI eligible when a request for the STAR+PLUS HCBS program is received on the interest list hotline. Program Support Unit (PSU) staff must use the CSIL database to track NF residents who are not SSI eligible when a request for the STAR+PLUS HCBS program is received from a Community Care Services Eligibility (CCSE) case manager. ILM Unit or PSU staff must check the CSIL database to verify if the NF resident is on the STAR+PLUS HCBS program interest list when a request for community transition to the STAR+PLUS HCBS program is received. ILM Unit or PSU staff must add, if applicable, and immediately release and assign the individual from the STAR+PLUS HCBS program interest list to pursue the Money Follows the Person (MFP) process if the individual is not in the CSIL database.

ILM Unit staff perform the following activities for individuals who request placement on the STAR+PLUS HCBS program interest list:

  • Place individuals on the interest list;
  • Maintain annual contact requirements;
  • Release individuals from the interest list when funding is available;
  • Track STAR+PLUS HCBS program slots allocated for use by individuals who are not mandatory participants; and
  • Confirm individuals on the interest list are viable STAR+PLUS 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 STAR+PLUS HCBS 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 and will remain in that status until the individual notifies ILM Unit staff of continued interest.

The HHSC enrollment broker must contact all individuals by phone upon release from the STAR+PLUS HCBS program interest list to notify them of their names reaching the top of the list and a slot has become available.  

The enrollment broker will contact the individual to confirm if the individual wishes to pursue the STAR+PLUS HCBS program. The enrollment broker will mail the enrollment packet if the individual wishes to pursue the STAR+PLUS HCBS program. If the individual does not wish to pursue the STAR+PLUS HCBS program:

  • 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 interest list release (ILR) will be closed with the appropriate closure code in the CSIL database.

The enrollment broker will mail a STAR+PLUS HCBS program enrollment packet to all individuals released from the interest list and interested in pursuing STAR+PLUS HCBS program services. The STAR+PLUS HCBS program enrollment packet includes:

The enrollment broker contacts the individual every seven days from the date the enrollment packet is mailed. All enrollment broker contacts will cease when the completed packet is received by the enrollment broker or on the 30th day after mailing the enrollment packet, whichever is sooner. The enrollment broker’s contact attempts include the 14-day contact requirement.

The enrollment broker will contact the applicant or authorized representative (AR) to:

  • give a general description of STAR+PLUS HCBS program services;
  • provide a list of managed care organizations (MCOs) in their service area (SA) and encourage the member to contact one for service information;
  • discuss the importance of choosing an MCO so an assessment and initial individual service plan (ISP) can be completed in order to avoid a delay in eligibility determination for the STAR+PLUS HCBS program; and
  • inform the individual that their MCO selection can be changed at any time after the first month of service.

The enrollment broker will fax the signed and completed Form H1200, along with Form H1746-A, MEPD Referral Cover Sheet (PDF), to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days of receipt from the applicant or AR. The applicant or AR will select an MCO by completing Form H2053-B, Health Plan Selection (PDF), or notifying the enrollment broker verbally.

Refer to section 3312, Managed Care Enrollment, for steps to be taken after an individual is released from the STAR+PLUS HCBS program interest list.

3311.2 Enrollment Procedures Following Release from the Interest List

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff complete the following activities within three business days of the receipt of the STAR+PLUS Home and Community Based Services (HCBS) program 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 per the procedures below:
    • check the Service Authorization System Online (SASO) for open Service Authorization and Enrollment records for:
      • Community Living Assistance and Support Services (CLASS) (Service Group (SG) 2);
      • Deaf Blind and Multiple Disabilities (DBMD) (SG 16);
      • Home and Community-based Services (HCS) (SG 21); 
      • Texas Home Living (TxHmL) (SG 22); and 
  • upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), Section A, to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

The MCO must complete the following activities within 45 days from the date PSU staff upload Form H3676 to TxMedCentral:

  • upload Form H3676, Section B, to TxMedCentral;
  • conduct the Medical Necessity and Level of Care (MN/LOC) Assessment; and
  • develop the individual service plan (ISP) using Form H1700-1, Individual Service Plan, and upload it to TxMedCentral.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet (PDF), to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the applicant has an approved MN/LOC Assessment and ISP within two business days of receipt from the MCO.

PSU staff must notify Program Support Operations Review Team (PSORT) staff by email within two business days of an MCO failing to submit initial assessment information within the 45-day time frame. The email sent to PSORT staff must include:

  • an email subject line that reads: “STAR+PLUS HCBS Initial 45-Day XX [plan code] MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MCO non-compliance for Ann Smith would read “STAR+PLUS HCBS 45-Day 9B MCO Non-Compliance for AS”;
  • individual or applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
  • attach any pertinent documents received from the MCO (e.g., Form H2067-MC).

PSU staff must ensure the medical necessity (MN) determination from the Texas Medicaid & Healthcare Partnership (TMHP) nurse or physician is valid by verifying the approval date does not exceed 120 days. PSU staff must upload Form H2067-MC to TxMedCentral, following the instructions in Appendix XXXIV, advising the MCO to submit a new initial MN/LOC Assessment if the MN approval date exceeds 120 days.

PSU staff must determine if the applicant meets the eligibility criteria for the STAR+PLUS HCBS program within five business days from the MEPD specialist advising the applicant meets Medicaid financial eligibility. PSU staff must complete the following activities if the applicant meets the eligibility criteria:

  • generate Form H2065-D, Notification of Managed Care Program Services (PDF), following the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language;
    • Note: The start of care (SOC) date for the STAR+PLUS HCBS program is the first day of the month, following meeting all eligibility criteria. PSU staff processing does not delay the eligibility begin date.
  • mail Form H2065-D to the member;
  • create SASO entries following procedures in Section 9100, Initial Service Authorization;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV; 
  • fax Form H1746-A (PDF) and Form H2065-D to the MEPD specialist; 
  • notify Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
  • an email subject line that reads “STAR+PLUS HCBS Enrollment for XX [member’s first and last name initials].” For example, the email subject line for a ILR for Ann Smith would be “STAR+PLUS HCBS Enrollment for AS”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (i.e., ILR enrollment);
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment; 
    • Form H2065-D;
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
  • document and close the HEART case record.

Refer to section 6000, Denials and Terminations, if the applicant does not meet STAR+PLUS HCBS program requirements at ILR.

3311.3 Interest List Slot Allocations

Revision 18-0; Effective September 4, 2018

Members receiving Medicaid services under any of the programs listed in the chart below must receive those services through managed care. This does not impact the STAR+PLUS member's right to access non-Medicaid services through the Texas Health and Human Services Commission (HHSC). STAR+PLUS Home and Community Based Services (HCBS) program members must receive all services through the STAR+PLUS HCBS program, excluding hospice care. Only STAR+PLUS HCBS members count against slot allocations, as the following table illustrates.

Texas Integrated Eligibility Redesign System (TIERS) Type of Assistance (TA)Program DescriptionCounts Against Interest List Slot Allocation?
TP 03Medical assistance only (MAO) Medicaid – PickleNo
TA 03Manual Supplemental Security Income (SSI) recipient waiversNo
TA 02 SSI recipient waiversNo
TP 13 SSI MedicaidNo
TA 10 Medicaid waiversYes
TP 18Medicaid for Disabled Adult Children (DAC)No
TP 21 Disabled Widows/Widowers MedicaidNo
TA 01SSI Denied ChildNo
TP 22 Early aged Widows/Widowers MedicaidNo
TP 51 Rider 51 waiversNo
TP 87Medicaid Buy-inNo

3311.4 Earliest Date for Adding a Member Back to the Interest List

Revision 18-0; Effective September 4, 2018

The earliest date an applicant or member may be added back to the Community Services Interest List (CSIL) database for STAR+PLUS HCBS is the date the applicant is determined to be ineligible for the program or the first date the member is no longer eligible for the program.

Example 1: The applicant is released from the STAR+PLUS HCBS program interest list on March 2, 2019. PSU staff send Form H2065-D, Notification of Managed Care Program Services (PDF), notifying the applicant is not eligible for the STAR+PLUS HCBS program on March 28, 2019. The first date the denied applicant can be added back to the STAR+PLUS HCBS program interest list is March 28, 2019.

Example 2: A STAR+PLUS HCBS program member is determined ineligible on March 28, 2019. PSU staff send Form H2065-D to the STAR+PLUS HCBS program member notifying of program termination. Termination is effective April 30, 2019. The first date the denied member can be added back to the STAR+PLUS HCBS program interest list is May 1, 2019.

If the applicant or STAR+PLUS HCBS program member’s name is added back to the interest list prior to the last date of program eligibility, the CSIL database interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program.

3311.5 Updating Community Services Interest List Records

Revision 18-0; Effective September 4, 2018

The Community Services Interest List (CSIL) database must be updated to reflect accurate information. Program Support Unit (PSU) staff must complete data entry in the CSIL database for STAR+PLUS Home and Community Based Services (HCBS) program actions within five business days of the date:

  • PSU staff sign Form H2065-D, Notification of Managed Care Program Services (PDF), certifying or denying applications, except Money Follows the Person (MFP) certifications; and
  • the request for other CSIL database actions (updating information, transferring an individual to another region's interest list or removing a member from the interest list upon request by the individual).

For MFP certifications, the CSIL database is updated when the Service Authorization System Online (SASO) data entry is completed to register the initial individual service plan (ISP). Delaying data entry of the disposition in CSIL for an applicant certified through MFP provisions prevents removing the individual from the interest list before the actual discharge from the nursing facility (NF) is verified.

PSU staff must ensure CSIL database closures are recorded accurately by using the Community Services Interest List (CSIL) User's Guide, available to PSU staff on SharePoint.

3311.6 Contacting the Interest List Management Unit to Reopen a Closed Interest List Release

Revision 20-6; 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 Community Services Interest List (CSIL) record.

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

  • an email subject line that reads: “S+P 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 “S+P Reopen Request for AS”;
  • individual’s name;
  • interest list identification (ID) number;
  • individual’s Medicaid ID number or Social Security number (SSN);
  • the individual’s or authorized representative’s (AR’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 STAR+PLUS HCBS.

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 XXXIII, STAR+PLUS HEART Naming Conventions; and
  • keep the HEART case record open until STAR+PLUS HCBS program 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 XXXIII; and
  • close the HEART case record.

3312 Managed Care Enrollment

Revision 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) enrollment broker mails enrollment packets to all Medicaid individuals who are candidates for STAR+PLUS. The enrollment packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the individual can choose. Individuals can return enrollment forms by mail, complete an enrollment form at an enrollment event or presentation, or call the HHSC enrollment broker and enroll by telephone at 800-964-2777.

Individuals have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the individual will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Individual assignments to an MCO or PCP are automatic, using a default process. Individuals assigned through the default process may change their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, the individual must receive Medicaid services through the assigned MCO and PCP until the individual contacts the MCO or the HHSC enrollment broker at 800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity (MN) determination is required.

3313 Termination of CCSE Services Upon STAR+PLUS HCBS Program Enrollment

Revision 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must coordinate the termination of Community Care Services Eligibility (CCSE) with the CCSE case manager. This is so the member does not experience a break in services and does not receive concurrent services through another waiver or CCSE service.

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

  • identify the CCSE case manager by viewing the Authorizing Agent screen in the Service Authorization System Online (SASO); 
  • email the CCSE case manager and CCSE supervisor the following information: 
    • a subject line that reads “CCSE Closure – STAR+PLUS HCBS Enrollment XX [first letter of the member’s first and last name]”;
    • member’s name;
    • Medicaid ID;
    • start of care (SOC) date for STAR+PLUS Home and Community Based Services (HCBS) program; and
    • managed care organization (MCO).
  • ensure the SASO reflects the closure of CCSE records with Service Group 7 and have an end date one day before the SOC for the STAR+PLUS HCBS program; and
  • follow instructions in section 3311.2, Enrollment Procedures following Release from the Interest List, to complete STAR+PLUS HCBS program enrollment.

PSU staff must encourage the member to contact the MCO to request any CCSE services not included in the STAR+PLUS HCBS program individual service plan (ISP).

3313.1 Procedure for STAR+PLUS HCBS Program Applicants

Revision Notice 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care Services Eligibility (CCSE) services with the waiver or CCSE case manager for individuals entering the STAR+PLUS Home and Community Based Services (HCBS) program. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCSE service.

The CCSE case manager terminates CCSE services in the Service Authorization System Online (SASO) no later than one day prior to the STAR+PLUS HCBS program enrollment. The adverse action notification period does not apply in this situation.

The CCSE case manager must send:

3313.2 Procedure for STAR+PLUS HCBS Program Members

Revision 18-0; Effective September 4, 2018

If it is determined an existing STAR+PLUS Home and Community Based Services (HCBS) program member is receiving any Service Group (SG) 7 Community Care Services Eligibility (CCSE) services, Program Support Unit (PSU) staff must begin denial procedures for the SG 7 service immediately.

If CCSE services are authorized in SASO, the CCSE case manager must immediately send:

3314 Managed Care Organization Changes

Revision 18-0; Effective September 4, 2018

Members may change managed care organization (MCO) plans as often as monthly by contacting the Texas Health and Human Services Commission (HHSC) enrollment broker at 800-964-2777. The HHSC enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of each month. Depending on which day of the month (before or after the HHSC enrollment broker cutoff), the plan change will either occur the first day of the next month or the month after. The change will show up on the 834 daily enrollment file, notifying the MCO of the new member. Program Support Unit staff, when notified by the member, HHSC or an MCO that a member has elected to change MCOs, will update the Service Authorization System Online (SASO) to change the previous MCO to the new MCO.

3315 STAR+PLUS HCBS Program Individuals Requesting Non-Managed Care Services

Revision 18-0; Effective September 4, 2018

Requirements of the STAR+PLUS Home and Community Based Services (HCBS) program provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for the STAR+PLUS HCBS program member. A STAR+PLUS HCBS program member requesting additional services must be referred to the managed care organization's (MCO’s) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

3315.1 Requests from Individuals Awaiting Managed Care Enrollment

Revision 18-0; Effective September 4, 2018

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care Services Eligibility (CCSE) program. Referrals to CCSE must be made for all full Medicaid recipients awaiting enrollment for managed care. CCSE staff may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

3315.2 Requests from STAR+PLUS HCBS Program Members

Revision 18-0; Effective September 4, 2018

Requirements of the federal 1115 waiver dictate that the STAR+PLUS Home and Community Based Service (HCBS) program provide the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's (MCOs) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

3316 Transfer from Another Medicaid Waiver Program to the STAR+PLUS HCBS Program

Revision 24-1; Effective Feb. 22, 2024

Individuals in the following Medicaid waiver programs may request an assessment for the STAR+PLUS Home and Community Based Services (HCBS) program at any time:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS);
  • Home and Community Based Services – Adult Mental Health (HCBS-AMH) program; or
  • Texas Home Living (TxHmL).

Program Support Unit (PSU) supervisors receives a report by email from Interest List Management (ILM) Unit staff. The email identifies STAR+PLUS HCBS program interest list release individuals currently enrolled in another Medicaid waiver program. PSU staff may also receive a referral from Medicaid waiver program staff if an individual is enrolled in another Medicaid waiver program and is requesting the STAR+PLUS HCBS program. Refer any Medicaid waiver program transfer request received from the managed care organization (MCO) or Local Intellectual and Developmental Disability Authority (LIDDA) to the PSU supervisor. 

PSU staff must mail the following enrollment packet to the individual within three business days of the initial request for a STAR+PLUS HCBS program assessment:

PSU staff must contact the individual or authorized representative (AR) to verify receipt of the enrollment packet and explain the STAR+PLUS HCBS program services within 14 days from the mail date of the above enrollment packet. PSU staff must:

  • encourage the individual to complete the enrollment packet and mail it back; and
  • inform the individual that there might be a delay in eligibility determination for the STAR+PLUS HCBS program if the individual does not return the enrollment packet.

PSU staff can accept the individual’s or AR’s verbal statement of interest in the STAR+PLUS HCBS program or through receipt of Form H3675.

PSU staff must document all attempted contacts with the individual or encountered delays in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), to the MCOHub within two business days of the individual’s or AR’s confirmed interest in the STAR+PLUS HCBS program.

The MCO must complete the following activities within 45 days from the date PSU staff upload Form H3676 to the MCOHub:

  • submit the Medical Necessity and Level of Care (MN/LOC) Assessment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • submit the individual service plan (ISP) in the TMHP LTCOP; and
  • complete and upload Section B of Form H3676 to the MCOHub.

PSU staff must email the Program Support Operations Review Team (PSORT) if the MCO does not provide the MN/LOC Assessment, Form H1700-1 or Form H3676 within 45 days from the date PSU staff uploads Form H3676 to the MCOHub.

PSU staff must complete the following activities within two business days of receipt of all required STAR+PLUS HCBS program eligibility documentation:

  • confirm STAR+PLUS HCBS program eligibility by verifying the individual:
    • is over 21 in the Texas Integrated Eligibility Redesign System (TIERS);
    • has Medicaid eligibility for the STAR+PLUS HCBS program in TIERS;
    • has an approved MN/LOC Assessment in the TMHP LTCOP;
    • has an individual service plan (ISP) with at least one STAR+PLUS HCBS program service; and
    • has an ISP Resource Utilization Group (RUG) value within the individual’s cost limit.

PSU staff must approve the applicant’s enrollment in the STAR+PLUS HCBS program the first day of the following month after verifying all STAR+PLUS HCBS program eligibility criteria are met.

PSU staff must complete the following activities within two business days of verifying all STAR+PLUS HCBS program eligibility criteria are met:

  • manually or electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF), with a SOC date being the first day of the month following the other Medicaid waiver program's termination;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub, if manually generated;
  • notify the Enrollment Resolution Services (ERS) Unit staff by email with the following required information:
    • an email subject line that reads “Waiver Transfer Request for XX [first letter of the member’s first and last name]”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., waiver transfer);
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO;
    • termination effective date for the other Medicaid waiver program;
    • effective date of enrollment for the STAR+PLUS HCBS program; and
    • Form H2065-D.
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the STAR+PLUS HCBS program start of care (SOC) date and the termination date for the other Medicaid waiver program;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

PSU staff must coordinate with all other Medicaid waiver program staff, as appropriate, ensuring the current Medicaid waiver program services end the day before enrollment in the STAR+PLUS HCBS program.

Title 1 Texas Administrative Code (TAC) Section 353.1153(a)(1)(F) states that STAR+PLUS HCBS program members cannot be enrolled in more than one Medicaid waiver program at a time. Refer to Appendix XVIII, Mutually Exclusive Services, to determine if two services may be received simultaneously.

3317 Transfer from STAR+PLUS HCBS Program to Another Medicaid Waiver Program

Revision Notice 24-1; Effective Feb. 22, 2024

Title 1 Texas Administrative Code (TAC) Section 353.1153(a)(1)(F) states that STAR+PLUS Home and Community Based Services (HCBS) members are not able to enroll in more than one Medicaid waiver program at a time. Refer to Appendix XVIII, Mutually Exclusive Services, to determine if a member may receive two services simultaneously.

A STAR+PLUS HCBS program member may be on an interest list for an Intellectual and Developmental Disabilities (IDD) Medicaid waiver program, such as:

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

A STAR+PLUS HCBS program member may also be eligible for another waiver such as the Home and Community Based Services – Adult Mental Health (HCBS-AMH) program that does not have an interest list.

Program Support Unit (PSU) staff may receive notification from Medicaid waiver program staff or the managed care organization (MCO) that the STAR+PLUS HCBS program member:

  • is eligible for another Medicaid waiver program;
  • chooses to transfer to another Medicaid waiver program; or
  • is already enrolled in another Medicaid waiver program.

PSU staff must coordinate the program enrollment effective date with IDD waiver program staff. PSU staff must request confirmation of the program enrollment and the enrollment effective date from the IDD waiver program staff if the MCO or Local Intellectual and Developmental Disability Authority (LIDDA) notifies PSU staff of a waiver transfer. The IDD waiver program staff must confirm the member’s enrollment effective date. 

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

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, if applicable;
  • contact and coordinate with Medicaid waiver program staff by email to determine the STAR+PLUS HCBS program termination date and the start of care (SOC) date for the other Medicaid waiver program;
  • terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in SASO the last day of the month before the member’s enrollment in the Medicaid waiver program:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization.
  • manually generate Form H2065-D, Notification of Managed Care Program Services, with a termination effective date one day before other Medicaid waiver’s start of care (SOC) date;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub;
  • notify the Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
    • an email subject line that reads “Waiver Transfer Request for XX [first letter 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 Request for AS”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., waiver transfer);
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO;
    • termination effective date for the STAR+PLUS HCBS program;
    • enrollment effective date for the other Medicaid waiver program; and
    • Form H2065-D (PDF);
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the STAR+PLUS HCBS program termination date and the start of care (SOC) date for the other Medicaid waiver program;
  • upload all applicable documents to the HEART case record; and
  • document and close the HEART case record.

Note: PSU staff must not close Medical Necessity, Level of Service, and Diagnostic SG 19 – STAR+PLUS records in SASO.

3320 Coordination with Medicaid for the Elderly and People with Disabilities

Revision 18-0; Effective September 4, 2018

3321 General Eligibility Issues

Revision 18-0; Effective September 4, 2018

At the initial contact, Program Support Unit (PSU) staff must inform the medical assistance only (MAO) applicant, member or authorized representative (AR) that Medicaid for the Elderly and People with Disabilities (MEPD) specialists will complete a financial eligibility (Medicaid) determination. PSU staff should encourage the applicant, member or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

Any information, including information on third-party insurance, obtained by PSU staff, must be shared with the MEPD specialist to prevent the applicant or member from having to provide the information twice.

PSU staff must inform the MEPD specialists of the request for the STAR+PLUS Home and Community Based Services (HCBS) program by faxing a completed and signed Form H1200, Application for Assistance – Your Texas Benefits (PDF), along with Form H1746-A, MEPD Referral Cover Sheet (PDF), following the guidelines provided in Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, within two business days of receipt. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

3321.1 Disability Determinations

Revision 18-0; Effective September 4, 2018

The following information is provided for informational purposes only regarding the disability determination process. Program Support Unit (PSU) staff have no role in this process.

If a STAR+PLUS HCBS program applicant or member's application for Supplemental Security Income (SSI) disability has been pending over 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. PSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, the MEPD specialist must obtain the following:

3322 Actions Pending Past the MEPD Due Date

Revision 18-0; Effective September 4, 2018

Because Program Support Unit (PSU) staff depend on the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to determine eligibility for medical assistance only (MAO) applicants, there are times when PSU staff must check with the MEPD specialist regarding the status of an application or program change.

PSU staff must contact the MEPD specialist by sending an email to the HHSC OES MEPD IC mailbox. PSU staff must ensure the MEPD time frame has expired. MEPD specialists have 45 days to complete applications for individuals over age 65. MEPD specialists have 90 days for individuals under age 65 whose disability has not yet been determined by the Social Security Administration (SSA).

3330 STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS HCBS Program

Revision 22-1; Effective January 31, 2022

Medicaid members enrolled in STAR+PLUS qualify for Medicaid eligibility through various program types. Some members who request the STAR+PLUS Home and Community Based Services (HCBS) program may be Medicaid eligible through one of the following Medicaid program types (TPs):

  • Pickle (TP-03);
  • Disabled Adult Child (TP-18);
  • Disabled Widow(er) (TP-21);
  • Early Aged Widow(er) (TP-22);
  • Medicaid Buy-in (TP-87); or
  • Medicaid for Breast and Cervical Cancer (MBCC) (TA-67).

The above Medicaid programs represent full Medicaid eligibility; however, they do not consider transfer of assets and substantial home equity reviews required to establish financial eligibility for the STAR+PLUS HCBS program. Therefore, these Medicaid types are not eligible for an upgrade and enrollment in the STAR+PLUS HCBS program until the Medicaid for the Elderly and People with Disabilities (MEPD) specialist tests for the additional criteria.

The managed care organization (MCO) must notify the Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication (PDF), to TxMedCentral within three business days of an upgrade request for a member who has one of these Medicaid program types. PSU staff must contact the member within three business days of receiving Form H2067-MC to advise the member to complete and return Form H1200, Application for Assistance - Your Texas Benefits (PDF), to PSU staff.

PSU staff fax the signed and completed Form H1200 and Form H1746-A, MEPD Referral Cover Sheet (PDF), to the MEPD specialist within two business days of receipt from the member. PSU staff must refer to Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, when completing Form H1746-A.

The MCO service coordinator must complete the following activities within 45 days of a STAR+PLUS individual’s request for the STAR+PLUS HCBS program:

PSU staff review Form H1700-1 to determine if the member meets eligibility criteria for the STAR+PLUS HCBS program within five business days of receipt of Form H1700-1 from the MCO.

The MCO must inform PSU staff within three business days by uploading Form H2067-MC to TxMedCentral if an MN/LOC Assessment for an upgrade is denied. PSU staff fax Form H1746-A and Form H2065-D, Notification of Managed Care Program Services (PDF), to the MEPD specialist as notification of denial within three business days of PSU staff receiving Form H2067-MC from the MCO.

PSU staff must complete the following activities if an applicant does not meet STAR+PLUS HCBS program eligibility requirements:

  • follow actions in section 6000, Denials and Terminations, to deny the request;
  • mail Form H2065-D (PDF) within three business days to the applicant; and
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV.

PSU staff will process the member’s upgrade if the member is eligible by:

  • manually generating Form H2065-D and mailing it to the member;
  • uploading Form H2065-D in TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV;
  • faxing Form H1746-A and Form H2065-D to the MEPD specialist; and
  • confirming Service Authorization System Online (SASO) entries to authorize eligibility for the STAR+PLUS HCBS program are complete and accurate. PSU staff will correct existing SASO records as needed.

3400, Transferring Into STAR+PLUS

Revision 18-0; Effective September 4, 2018

Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services (PAS). STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Case Manager Community Care for Aged and Disabled (CM-CCAD) Handbook, Section 2230, Interest List Procedures.

Any application for new long-term services and supports (LTSS) from HHSC requires the mandatory member to be sent to his or her MCO first. This must be coordinated through Program Support Unit (PSU) staff. Refer to Section 3125, STAR+PLUS HCBS Members Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for general revenue (GR) funds. For these applicants or members, the losing service area must inform the gaining service area of the GR status. The gaining service area must follow the GR process.

3410 MCO Transfer Scenarios

Revision Notice 24-2; Effective May 21, 2024

The applicant, member, or authorized representative (AR) must contact the enrollment broker by phone at 800-964-2777 to change from one managed care organization (MCO) to another MCO. The MCO transfer may occur within the same service area (SA) or in another SA.

An applicant, member, or AR may request to change MCOs at any time, for any reason, and regardless of their living arrangement. However, for an applicant requesting an MCO change, the transfer will not go into effect until after one full calendar month of STAR+PLUS Home and Community Based Services (HCBS) program service provision. All MCO enrollment changes become effective based on the date the MCO change is requested and processed, in relation to the state cutoff. Refer to Appendix XVII, State Cutoff Dates, for more information.

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes Report to PSU staff and gaining MCOs. PSU staff receive a complete list of all plan changes and the MCO receives a list of their new members. The report lists STAR+PLUS HCBS program members who have changed MCOs from the previous month. Refer to Appendix I-E, Monthly Plan Changes Report, for information on the contents of the report.

3411 Transferring from One MCO to Another Within the Same Service Area

Revision Notice 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must ensure the contract number in the Service Authorization System Online (SASO) is updated to reflect the new managed care organization’s (MCO’s) contract number. This must be done within 14 days of receipt of the Monthly Plan Changes Report from Enrollment Operations Management (EOM) staff. Refer to Section 9300, Transfers, for more information on SASO actions.

The losing MCO must transfer all relevant information to the gaining MCO using a secure file transfer protocol (SFTP) or secure email. Relevant information includes the individual service plan (ISP), Medical Necessity and Level of Care (MN/LOC) Assessment, and Form H2065-D, Notification of Managed Care Program Services. 

The gaining MCO is responsible for service delivery beginning the first day of enrollment. The gaining MCO honor authorizations included in the prior ISP until the member requires a new MN/LOC Assessment.

The gaining MCO must notify Managed Care Compliance and Operations (MCCO) staff if they encounter issues getting the transfer packet from the losing MCO. MCCO Unit staff may contact PSU staff for help transferring member information to the gaining MCO.

3412 Transferring from One MCO to Another in a Different Service Area

Revision Notice 24-2; Effective May 21, 2024

The losing Program Support Unit (PSU) staff must complete the following activities within five business days of receipt of the Monthly Plan Change report from Enrollment Operations Management (EOM) staff for an applicant or member changing service areas (SAs):

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • verify the applicant or member’s address and managed care enrollment is updated in Texas Integrated Eligibility Redesign System (TIERS);
  • email the gaining PSU staff  the following information: 
    • an email subject line that reads “STAR+PLUS HCBS MCO Transfer for XX [applicant or member’s first and last name initials]”;
    • applicant or member name;
    • Medicaid identification (ID) number;
    • current and future contact information; 
    • date of the move or anticipated move; and
    • Form H1700-1, Individual Service Plan, if available.

The losing PSU staff must complete the following activities within two business days of determining an applicant or member does not have an updated address or managed care enrollment in TIERS:

  • for Supplemental Security Income (SSI) applicants and members: 
    • advise the MCO to help the applicant or member to contact the Social Security Administration (SSA) to update their address; and
  • for medical assistance only (MAO) applicants and members:
    • fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist noting the address change.

TIERS will attempt to assign an applicant or member to a companion plan automatically when their address is updated in TIERS and reflects a SA change. A companion plan is defined as an MCO that operates the same managed care line in multiple SAs. TIERS will systematically refer the applicant or member to the enrollment broker if a companion plan is unavailable.

The enrollment broker will attempt to get a new MCO selection from the member. The enrollment broker will default the member to an MCO if a selection is not provided within 15 days. The defaulted MCO selection is made using the Texas Health and Human Services Commission (HHSC) approved default logic and is processed at the next state cutoff. The HHSC-approved default logic considers the member’s medical history, including prior enrollments, primary care providers (PCPs), claims data, and any family plans, about the program type and SA.

For applicants, the gaining PSU staff must ensure the MCO submits the Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP) within 45 days from the date the losing PSU staff upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub.

For members, the gaining PSU staff must confirm all STAR+PLUS Home and Community Based Services (HCBS) program eligibility within five business days of receipt of Form H1700-1. The process is abbreviated since the member already has the following:

  • an MN/LOC Assessment;
  • a Resource Utilization Group (RUG); and
  • financial eligibility determination by the MEPD specialist, if applicable.

The gaining PSU staff coordinates all appropriate activities between the losing PSU staff, MCOs, applicant, member or authorized representative (AR), Enrollment Resolution Services (ERS) Unit staff and other key parties to help ensure a successful transition.

The gaining PSU staff must complete the following activities within five business days from notification of the transfer:

  • confirm the applicant or member’s address and managed care enrollment is updated in TIERS;
  • ensure the contract number in the Service Authorization System Online (SASO) is updated to reflect the gaining MCO’s contract number;
  • for MAO members, email ERS Unit staff the following information:
    • an email subject line that reads “STAR+PLUS HCBS MCO Transfer Enrollment Request for XX [member’s first and last name initials]”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (i.e., MCO change);
    • medical necessity (MN) approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment; 
  • upload all applicable documents to the HEART case record; and
  • document and close the HEART case record.

The gaining PSU staff must complete the following activities within two business days of determining an applicant or member does not have an updated address or managed care enrollment in TIERS:

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for more information, and for SA changes occurring for a Money Follows the Person (MFP) case.

3420 Individuals Transitioning Services for Adults

Revision 18-0; Effective September 4, 2018

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults beginning the first day of the first month following the individuals 21st birthday. The following services end at the end of the month following the member's 21st birthday.

  • Medically Dependent Children Program (MDCP) operated by STAR Kids or STAR Health managed care organizations (MCOs); and
  • Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

In addition to the programs and services above, individuals for Community First Choice (CFC) services and personal care services (PCS) must transition to an adult program.

Members who receive MDCP, PDN, PPECC, CFC or PCS and transition to adult programs may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC

Revision 18-0; Effective September 4, 2018

Members may receive a combination of the following services:

  • Medically Dependent Children Program (MDCP);
  • private duty nursing (PDN); or
  • prescribed pediatric extended care center (PPECC) services.

3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Twelve months prior to the 21st birthday of a STAR Kids or STAR Health member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Unit provides a copy of the MDCP-PDN Transition Report, which lists members enrolled in STAR Kids or STAR Health receiving MDCP, CCP/PDN or PPECC services, who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months to the:

  • Program Support Unit (PSU) staff; and
  • UR Unit for Intellectual or Developmental Disabilities (IDD) Waiver/Community Services/Hospice staff.

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning age 21 within the next 12 months and schedule a face-to-face visit with the member and the member's support person including the authorized representative (AR), if applicable, to initiate the transition process.

During the home visit with the member, member's support person or AR, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to the STAR+PLUS program. Specific information that must be provided during the face-to-face visit can be found in the STAR Kids Program Support Unit Operational Procedures Handbook, Appendix VI, STAR Kids Transition Activities, or for STAR Health, in the Uniform Managed Care Manual (UMCM).

The STAR Kids MCO must:

  • make a referral to Program Support Unit (PSU) staff by email at the Managed Care Program Support mailbox, using Form H2067-MC, Managed Care Programs Communication, and include, "PDN/PPECC and/or MDCP Transition" in the subject line;
  • monitor transition activities with the member or the support person, including the AR, every 90 days during the year before the member turns age 21; and
  • email the UR Unit mailbox indicating this may be a high needs member, if the member appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program.

The STAR Health MCO:

  • emails the UR Unit mailbox if the member appears to meet the high needs criteria below:
    • the member is on ventilator care; and/or
    • the member has high skilled nursing needs, such as tracheostomy care, wound care, suctioning or feeding tubes.

The UR Unit Transition/High Needs coordinator must:

  • monitor the MDCP-PDN Transition Report and identify all STAR Health members turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); or
    • Texas Home Living (TxHmL); and
  • coordinate with UR Unit staff for the IDD waivers and PSU staff if it is determined the member has high needs and/or needs to be assessed for the STAR+PLUS HCBS program.

ILM Unit staff must:

  • monitor the Managed Care Program Support mailbox for referrals submitted with the subject line "PDN/PPECC and/or MDCP Transition";
  • perform a search prior to assigning the referral to see if a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record has been created by PSU staff from monitoring the CCP Transition Report; and
  • if a HEART case record is found, upload the MCO's referral and advise PSU staff by email; or
  • if a HEART case record is not found, create a HEART case record, upload the referral and assign to PSU staff for further action.

PSU staff must:

  • monitor the MDCP-PDN Transition Report and identify all members receiving MDCP, PDN or PPECC services turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL;
  • create a case record in HEART noting:
    • if the MCO determines the member is high needs; the program type (MDCP, or PDN or PPECC) the member is transitioning from; and
    • the due date for the nine-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder earlier than five months prior to the member's 21st birthday.

The following chart outlines the responsibilities for monitoring the MDCP-PDN Transition Report and contacting members transitioning from STAR Kids or STAR Health who receive MDCP, PDN or PPECC 12 months prior to the member's 21st birthday.

12-Month Transition Chart

Under Age 21 MDCPUnder Age 21 Other Services ReceivedMonitors MDCP-PDN Transition Report12-Month Contact
MDCPPDN-CCP or PPECC-CCPPSU StaffMCO
MDCPNonePSU StaffMCO
Not ApplicablePDN-CCPPSU StaffMCO
Not ApplicablePPECC-CCPPSU StaffMCO

3421.2 Nine Months Before the Member's 21st Birthday

Revision 23-4; Effective Dec. 7, 2023

Nine months before the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and STAR Health managed care organization (MCO) must:

  • monitor transition activities with the member and the member's available supports, including his or her authorized representative (AR), every 90 days during the year before the member turns 21; and
  • notify Program Support Unit (PSU) staff of any issues or concerns by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

PSU staff must:

  • monitor the MDCP-PDN Transition Report and identify all members transitioning from STAR Kids and receiving MDCP and PDN or PPECC turning 21 in nine months and not enrolled in one of the following 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);
  • mail the STAR Kids member or AR a STAR+PLUS enrollment packet, including:

PSU staff must update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record by:

  • documenting the date Form 2114 was sent out to the member or AR;
  • documenting the due date for the phone contact 30 days from the date the STAR+PLUS Home and Community Based Services (HCBS) program enrollment packet is mailed; and
  • upload all applicable documents to the HEART case record.

Note: PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub no earlier than five months before the member's 21st birthday.

PSU staff must contact the member or AR within 30 days from the date the enrollment packet was mailed to discuss:

  • The transition process and review the enrollment packet.
  • STAR Kids eligibility, MDCP, PDN and PPECC services will terminate on the last day of the month that the member's 21st birthday occurs.
  • The STAR+PLUS HCBS program is an option available to eligible members at 21. PSU staff must also present an overview of the array of services available within the STAR+PLUS HCBS program.
  • The STAR+PLUS HCBS program enrollment packet sent to the member is reviewed. The enrollment packet contains a list of the STAR+PLUS MCOs in the SA and a comparison chart to help the member in making an MCO selection. The member will choose a STAR+PLUS MCO in their SA to conduct the Medical Necessity and Level of Care (MN/LOC) Assessment for services and oversee the delivery of services.
  • The importance of choosing an MCO six months before the 21st birthday to avoid having a gap in services.
  • The member can change MCOs any time after the first month of enrollment.
  • The STAR+PLUS HCBS program has a cost limit based on a medical assessment, the MN/LOC Assessment. The assessment determines the cost limit for the individual service plan (ISP).
  • To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit, meet the member's needs and ensure health and safety.
  • The STAR+PLUS HCBS program will be denied if an ISP cannot be developed within the cost limit that ensures member's health and safety in the community.
  • The ISP considers all resources available to meet the member's needs, including community supports, other programs, and what the member's informal support system can provide to meet the member's needs.
  • The STAR+PLUS HCBS program assessment process will begin six months before the member's 21st birthday. PSU staff will contact the member to begin the application process and find out which MCO has been selected. The member has 30 days to select an MCO. An MCO will be selected for the member after 30 days if one has not been selected.
  • The MCO service coordinator will contact the member to begin the MN/LOC Assessment for services and assist the member or AR identify and develop additional resources and community supports to help meet the member's needs.
  • The MCO service coordinator will help the member determine the services needed within this service array to meet his or her needs and ensure health and safety. Example: A member who primarily requires nursing services can have an ISP developed with the maximum number of nursing hours within the cost limit while the member's other needs are met through other resources.
  • Reassure the member or AR every effort will be made to ensure a successful transition to the STAR+PLUS HCBS program.
  • The member may potentially receive an enrollment packet from the Texas Health and Human Services Commission (HHSC) enrollment broker and the importance of selecting the same MCO.

PSU staff must update the HEART case record by noting the due date for the six-month contact.

The following chart outlines the responsibilities to monitor the MDCP-PDN Transition Report and contact members transitioning from STAR Kids or STAR Health and receiving MDCP and PDN or PPECC nine months before the member's 21st birthday:

Nine-Month Transition Chart

Under 21 MDCPUnder 21 Other Services ReceivedMonitors MDCP-PDN Transition Report:Nine-Month Contact:
MDCPPDN-CCP or PPECC-CCPPSU StaffPSU Staff
MDCPNonePSU StaffPSU Staff
NonePDN-CCPPSU StaffPSU Staff
NonePPECC-CCPPSU StaffPSU Staff

3421.3 Six Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Six months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care (PPECC) services, the following process begins.
The Utilization Review (UR) Unit must:

  • monitor the MDCP-PDN Transition Report and identify all members turning age 21 in six months receiving CCP/PDN through fee-for-service (FFS) or STAR Health and not enrolled in one of the following Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); or
    • Texas Home Living (TxHmL).
  • coordinate with Program Support Unit (PSU) staff if it is determined the member is high needs and/or will need to be assessed for the STAR+PLUS Home and Community Based Services (HCBS) program.

The IDD Waiver/Community Services/Hospice UR Unit staff will:

  • monitor the MDCP-PDN Transition Report for members enrolled in one of the following 1915(c) Medicaid waivers for IDD and who are turning age 21 in the next six months:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL; or
  • make a STAR+PLUS HCBS program referral to PSU staff by email using Form H2067-MC, Managed Care Programs Communication, for members requesting a STAR+PLUS HCBS program assessment, or whose proposed waiver plan exceeds the member cost limit for the IDD 1915(c) Medicaid waiver listed above.

PSU staff must:

  • monitor the MDCP-PDN Transition Report and identify all members referenced in Section 3421, Children Transitioning from STAR Kids or STAR Health Receiving MDCP or THSteps-CCP, PDN or PPECC, turning age 21 in six months and not enrolled in one of the IDD 1915(c) Medicaid waivers listed above;
  • not reach out to members in CLASS, DBMD, HCS or TxHmL, unless the IDD Waiver/Community Services/Hospice UR Unit submits a referral, as documented above;
  • send Form H2116, Age-Out MDCP and PDN Contact Letter, to the member if the MCO choice has not been obtained;
  • contact the member or authorized representative (AR) if the MCO choice has not been obtained by telephone to:
    • review the STAR+PLUS enrollment packet discussed at the 12-month or the nine-month contact;
    • inform the member or AR of a 30-day time frame to choose a managed care organization (MCO) and a primary care physician (PCP);
    • explain if the member or AR does not timely choose an MCO, the Texas Health and Human Services Commission (HHSC) will assign an MCO for the member; and
    • explain that the member can change MCOs any time after the first month of enrollment.
  • email the UR Unit at the HHSC UR High Needs CCR mailbox regarding all possible high needs situations; and
  • update the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, documenting the:
    • contact or contact attempt date;
    • MCO selection; and
    • due date for the five-month contact.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder earlier than five months prior to the member's 21st birthday.

The following chart outlines the responsibilities for agency referrals and PSU staff action for members enrolled in STAR Kids or STAR Health and receiving MDCP, PDN or PPECC transitioning six months prior to the member's 21st birthday.

Six-Month Transition Chart

Under Age 21 Current ProgramUnder Age 21 Other Services ReceivedPSU Staff Action
MDCPPDN-CCP or PPECC-CCPMonitors the MDCP-PDN Transition Report and contacts the member.
MDCPNot ApplicableMonitors the MDCP-PDN Transition Report and contacts the member.
Not ApplicablePDN-CCPMonitors the MDCP-PDN Transition Report and contacts the member.
Not ApplicablePPECC-CCPMonitors the MDCP-PDN Transition Report and contacts the member.
CLASS, DBMD, HCS or TxHmLNot Applicable, CCP/PDN or PPECCContacts the member when the referral is received.

3421.4 Five Months Prior to the Member's 21st Birthday

Revision 18-0; Effective September 4, 2018

Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps (THSteps) Comprehensive Care Program (CCP), private duty nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the member or authorized representative (AR) by telephone.

If the member or AR receiving MDCP or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

  • the member or AR receiving MDCP-PDN or PPECC informs PSU staff of the MCO choice; and
  • PSU staff inform the:
    • member that he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity;
    • MCO of the member's choice by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions; and
    • MCO of members receiving 50 or more PDN hours, by noting the PDH hours in the comments field of Form H3676, Section A.

If the member or AR has not made an MCO and PCP choice:

  • PSU staff inform the member or AR that if an MCO is not selected within seven days from the PSU staff contact, one will be assigned; and
  • if the selection is not made within seven days from the PSU staff contact, PSU staff:
    • select an MCO for the member;
    • inform the member that:
      • an MCO has been selected; and
      • he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity; and
  • inform the MCO of the choice by uploading Form H3676 to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

Note: Within 14 days of the PSU staff uploading date of Form H3676, the MCO must schedule the initial home visit with the MDCP or CCP or PDN member or AR.

3421.5 MCO Actions After Receiving Form H3676 Referral

Revision 23-2; Effective May 15, 2023

The managed care organization (MCO) must complete the following activities within 45 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, from Program Support Unit (PSU) staff:

  • conduct and submit the Medical Necessity and Level of Care (MN/LOC) Assessment to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP); 
    • Note: The MCO must not submit the initial MN/LOC Assessment earlier than 150 days prior to the member’s 21st birthday;
  • complete Form H1700-1, Individual Service Plan, Form H1700-2, Individual Service Plan – Addendum and Form H1700-3, Individual Service Plan – Signature Page;
  • upload Form H1700-1 to TxMedCentral, once an approved MN/LOC Assessment is received; and
  • complete Form H3676, Section B, and upload to TxMedCentral.

3421.6 Confirm STAR+PLUS HCBS Program Eligibility

Revision 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must confirm ongoing Medicaid eligibility in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, from the managed care organization (MCO).

PSU staff must coordinate with the Intellectual or Developmental Disability (IDD) waiver program staff by email, if the member is enrolled in an IDD waiver program, within five business days of receipt of the following from the MCO: 

  • Form H3676, Section B;
  • an approved and valid Medical Necessity and Level of Care (MN/LOC) assessment; and
  • the STAR+PLUS Home and Community Based Services (HCBS) program individual service plan (ISP).

The email to the IDD waiver program staff must include: 

  • a subject line that reads "[IDD waiver program acronym] Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name]"; 
  • member’s name;
  • Medicaid identification (ID) number;
  • the IDD waiver program termination date; and 
  • the STAR+PLUS HCBS program start of care (SOC) date.

PSU staff must confirm STAR+PLUS HCBS program eligibility no earlier than 45 days before the transition to an adult program. PSU staff must confirm STAR+PLUS HCBS program eligibility by verifying the following eligibility criteria:

  • an approved and valid MN/LOC Assessment submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) and updated in the Service Authorization System Online (SASO);
  • an ISP within the cost limit that includes at least one STAR+PLUS HCBS program service; and
  • continued Medicaid financial eligibility in the Texas Integrated Eligibility Redesign System (TIERS).

    Note: A valid MN does not exceed 150 days from the date of TMHP approval for applicants transitioning to an adult program. PSU staff must upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub requesting the MCO submit a new initial MN/LOC Assessment in the TMHP LTCOP if the MN exceeds 150 days from the date of TMHP approval.

PSU staff must complete the following activities within five business days of confirming approval of STAR+PLUS HCBS program eligibility:

  • establish the SOC date which is the first of the month following the member's 21st birthday;
    • SOC Date Examples:
      • A member receiving Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP), private duty nursing (PDN) or Prescribed Pediatric Extended Care Centers (PPECC) services has their 21st birthday on March 3, 2019. STAR+PLUS enrollment is effective April 1, 2019.
      • A member receiving MDCP or CCP, PDN or PPECC services has their 21st birthday on April 1, 2019. STAR+PLUS enrollment is effective May 1, 2019.
  • manually or electronically generate Form H2065-D, Notification of Managed Care Program Services;
  • upload Form H2065-D to the MCOHub, if manually generated; 
  • mail Form H2065-D to the member;
  • email Enrollment Resolution Services (ERS) Unit staff the following information:
    • an email subject line that reads: "[MDCP or IDD waiver program] Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name]";
    • the member's name;
    • Medicaid ID number;
    • ISP begin and end date for the STAR+PLUS HCBS program;
    • MCO selection and plan code; and
    • Form H2065-D;
    • fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist as notification of the program change from MDCP or an IDD waiver program to the STAR+PLUS HCBS program for medical assistance only (MAO) members;
    • verify IDD waiver program staff have closed IDD records in SASO, if applicable;
    • make SASO entries, following procedures in Section 9600, MDCP/CCCP Transitioning to STAR+PLUS HCBS Program;
    • upload applicable documents to the HHS Enterprise Administrative Report and Tracking System (HEART) case record; and
    • document and close the HEART case record.

Refer to Section 6000, Denials and Terminations, for more information on denying an applicant trying to transition to an adult program.

3421.7 ISP Cost Exceeds 202% of the RUG Cost Limit

Revision 23-2; Effective  May 15, 2023

The managed care organization (MCO) must provide documentation to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator if the individual service plan (ISP) cost exceeds 202 percent of the Resource Utilization Group (RUG) cost limit.

The UR Unit may request a clinical review of the case to consider the use of state General Revenue (GR) funds to cover costs exceeding the 202 percent cost limit. The UR Unit will provide the final determination letter to the MCO and Program Support Unit (PSU) staff if a clinical review is conducted. 

Note: HHSC UR staff will coordinate with the member, authorized representative (AR) and the MCO to discuss the process for HHSC to request the use of GR for services above the cost limit.

3422 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 individual or applicant must receive services through programs serving adults beginning the first day of the month following the individual's or applicant's 21st birthday.

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

The Texas Health and Human Services Commission (HHSC) 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. The HHSC enrollment broker will select an MCO for the individual or applicant if the individual or applicant has not made a selection after 15 days, as outlined in Title 1 Texas Administrative Code (TAC), §353.403(d)(3), Enrollment and Disenrollment.

3423 Intrapulmonary Percussive Ventilator

Revision 18-0; Effective September 4, 2018

Members who were approved for, and are using, an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by the Texas Health and Human Services Commission (HHSC) Office of the Medical Director (OMD).

3500, Money Follows the Person

Revision 18-0; Effective September 4, 2018

Refer to section 3311.1, Interest List Procedures, for information regarding use of the Community Services Interest List (CSIL) database to track Money Follows the Person (MFP) applications from individuals who are not yet members of a managed care organization (MCO).

3510 Money Follows the Person and Managed Care

Revision 18-0; Effective September 4, 2018

The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports (LTSS). For residents who need the STAR+PLUS Home and Community Based Services (HCBS) program, the managed care organization (MCO) will perform the functional assessment and service planning.

Note: MCOs can use an NF's Medical Necessity and Level of Care (MN/LOC) Assessment, and Program Support Unit (PSU) staff can accept an NF’s MN/LOC Assessment for MFP applicants as long as the MN/LOC Assessments are approved and have not yet expired. The NF’s MN/LOC Assessment may not be used for upgrades. Refer to section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS HCBS Program, for more information about upgrades.

One of the eligibility requirements for MFP is that the individual be approved for the STAR+PLUS HCBS program prior to leaving the NF. Individuals must reside in the NF until a final determination is made indicating approval of the STAR+PLUS HCBS program. Individuals leaving before receiving Form H2065-D, Notification of Managed Care Program Services, for an approval, are denied using Denial Code 39 (Other) in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

Once the assessment process has been completed and the resident is determined eligible for the STAR+PLUS HCBS program, the MCO must be prepared to initiate the individual service plan (ISP) upon notification of eligibility. Individuals are enrolled in managed care on the first day of the month in which discharge from the NF is planned. This flexible enrollment process only applies to MFP.

Refer to section 3310, Intake and Enrollment, for more information about MFP.

The MCO participates in community planning groups (for example, the Community Transition Team) and other activities related to the state's Promoting Independence (PI) Initiative.

3511 Money Follows the Person Procedure

Revision 18-0; Effective September 4, 2018  
   
A referral is made through the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) when a nursing facility (NF) resident wishes to receive services in the community through the STAR+PLUS Home and Community Based Services (HCBS) program. Community Care Services Eligibility (CCSE) intake staff must refer all Money Follows the Person (MFP) requests to Program Support Unit (PSU) staff. Referrals can be made by anyone, including family members, NF staff, relocation specialists and HHSC case managers.

3512 MFP Applications Pending Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018

In keeping with the Promoting Independence (PI) Initiative, the Program Support Unit (PSU) and managed care organizations (MCOs) staff are obligated to assist the nursing facility (NF) applicant or member who wants to return to the community by providing information and referrals to possible resources in the community. However, in situations where specific eligibility criteria will not be met in the foreseeable future, PSU staff have the option to deny the request for services. Time frames are set as a guideline for denying requests pending service arrangements.

A four calendar month time frame is the guideline used in determining pending, or denying, requests for services. The assessment process does not stop during this period; however, eligibility cannot be established until the member is ready to discharge from the NF.

Examples:

  • A STAR+PLUS Home and Community Based Services (HCBS) program applicant has a definite date of discharge within four calendar months from the date services were requested. Allow the referral to remain open until the applicant is ready to discharge and coordinate the transfer to the community.
  • A STAR+PLUS HCBS program applicant is in the process of making living arrangements that will allow him to leave the NF within four calendar months from the date services were requested. Allow the application to remain open.

If the applicant has an estimated date of discharge that may or may not go beyond the four calendar month period, PSU staff should keep the request for services open. Refer to Section 3513, Applications Pending More than Four Calendar Months Due to Delay in NF Discharge, for information about applications pending more than four calendar months.

3513 Applications Pending More than Four Calendar Months Due to Delay in NF Discharge

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) and managed care organization (MCO) staff must use their judgment and work with applicants who have arrangements pending, but not finalized. PSU staff should keep the request for services open if the applicant has an estimated discharge date that goes beyond a four calendar month period.

PSU staff must refer Money Follows the Person (MFP) cases pending beyond four calendar months to the PSU supervisor when an applicant: 

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

3514 STAR+PLUS Individual Residing in a Nursing Facility

Revision 22-3; Effective Sept. 27, 2022

The managed care organization (MCO) must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral to inform Program Support Unit (PSU) staff of an individual’s request to transition to the community through the Money Follows the Person (MFP) process.

PSU staff must complete the following activities within two business days of receipt of Form H2067-MC:

  • create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • check the Texas Integrated Eligibility Redesign System (TIERS) for the Medicaid type program (TP);
  • check the Community Services Interest List (CSIL) database to see if the individual is on an Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waiver interest list;
  • determine, according to the procedures below, if the member has either an open enrollment or services are temporarily suspended in an IDD 1915(c) Medicaid waiver:
    • check the Service Authorization System Online (SASO) to see if a service authorization record exists with an end date and termination code for:
      • Community Living Assistance and Support Services (CLASS) (Service Group (SG) 2);
      • Deaf Blind with Multiple Disabilities (DBMD) (SG 16);
      • Home and Community-based Services (HCS) (SG 21); or
      • Texas Home Living (TxHmL) (SG 22).
        • Note: A service authorization record containing an end date, but no termination code indicates the 1915(c) Medicaid waiver program is temporarily suspended.
  • upload Form H2067-MC to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, to inform the MCO if the individual is:
    • on an IDD 1915(c) Medicaid waiver interest list; or
    • enrolled in an IDD 1915(c) Medicaid waiver, including the enrollment status.

The MCO must complete the following activities within 45 days of becoming aware of an individual’s requesting to transition to the community:

  • Determine if the individual wishes to pursue the STAR+PLUS Home and Community Based Services (HCBS) program if he or she are temporarily suspended from a 1915(c) Medicaid waiver program.
  • Use the nursing facility (NF) Minimum Data Set (MDS) to determine medical necessity (MN) or conduct the Medical Necessity and Level of Care (MN/LOC) Assessment in lieu of the MDS.
    • The MCO must conduct the MN/LOC Assessment if there is no valid MDS.
    • A denied MN/LOC Assessment decision cannot be used to deny an applicant who has a valid MDS. The MDS and Resource Utilization Group (RUG) value must be used for the MN determination.
    • A MN record must be located in the SASO so the individual service plan (ISP) registration does not suspend. The SASO MN record must match the ISP effective dates. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
  • Upload Form H2067-MC to TxMedCentral if a Supplemental Security Income (SSI) or SSI-related member is receiving personal assistance services (PAS) or emergency response services (ERS).
  • Develop the ISP using Form H1700-1, Individual Service Plan (PDF).

PSU staff must send an email to the Program Support Operations Review Team (PSORT) mailbox within two business days of an MCO failing to submit initial assessment information within the 45-day timeframe. The email sent to the PSORT mailbox must include:

  • an email subject line that reads: “STAR+PLUS HCBS Initial 45-Day XX [plan code] MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MCO non-compliance for Ann Smith would read “STAR+PLUS HCBS 45-Day 9B MCO Non-Compliance for AS”;
  • individual or applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
  • attach any pertinent documents received from the MCO (e.g., Form H2067-MC).

Refer to section 9400, MFP Authorization for STAR+PLUS HCBS Program Applicant, for more information on SASO actions.

3514.1 STAR+PLUS Individual Transitioning to the Community with STAR+PLUS HCBS Program

Revision 24-2; Effective May 21, 2024

The managed care organization (MCO) must determine if the individual wants to pursue the STAR+PLUS Home and Community Based 2024Services (HCBS) program if he or she is temporarily suspended from another Medicaid waiver program. The person has the option to remain in their current Medicaid waiver program or choose the STAR+PLUS HCBS program. The MCO must:

PSU staff must complete the following activities within two business days of receipt of Form H2067-MC from the MCO advising that the individual has selected another Medicaid waiver program:

  • upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

PSU staff must complete the following activities within five business days of receipt of Form H2067-MC from the MCO notifying PSU staff the individual has selected the STAR+PLUS HCBS program:

  • add the individual to the STAR+PLUS HCBS program interest list in the Community Services Interest List (CSIL) database, if applicable;
  • immediately release and assign the individual from the interest list in the CSIL database;
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

The MCO must upload the following information to the MCOHub within 45 days of the individual’s request to transition into the STAR+PLUS HCBS program:

  • Form H1700-1, Individual Service Plan (PDF), if the individual service plan (ISP) has expired or one did not previously exist; and
  • Form H2067-MC notifying PSU staff if the nursing facility (NF) discharge date is known.

PSU staff must complete the following activities within five business days of receipt of all required documentation from the MCO:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid financial eligibility;
    • an approved Medical Necessity and Level of Care (MN/LOC) Assessment; and
    • an ISP with:
      • at least one STAR+PLUS HCBS program service per ISP year; and
      • a cost within the individual's cost limit; and
  • manually generate the initial Form H2065-D, Notification of Managed Care Program Services (PDF);
  • mail the initial Form H2065-D to the member;
  • upload the initial Form H2065-D to the MCOHub;
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

    Note: refer to Form H2065-D instructions for more information on field entries.

The MCO collaborates with the relocation specialist, NF, applicant and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC to the MCOHub within two business days of the discharge date being determined. PSU staff must upload Form H2067-MC to the MCOHub within two business days of being notified by any other entity of a different NF discharge date, inquiring which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to the MCOHub advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to the MCOHub within two business days of the date the applicant is discharging from the NF.

PSU staff must complete the following activities within five business days of being notified of the NF discharge:

  • manually generate the second Form H2065-D;
  • mail the second Form H2065-D to the member;
  • upload the second Form H2065-D to the MCOHub;
  • fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
  • verify that NF records in the Service Authorization System Online (SASO), Service Groups (SG) 1 and 3, reflect the NF end date;
    • contact HHSC Long Term Care (LTC) Provider Claims Services at 512-438-2200 and select option 1 to request closure of the NF service authorization in SASO if the NF end date has not processed within five business days from the date of discharge;
  • close the CSIL database record using the appropriate closure code;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

    Note: Refer to Form H2065-D instructions for more information on field entries.

PSU staff must create SASO entries documented in section 9400, MFP Authorization for STAR+PLUS HCBS Program Applicant, within one business day of mailing the second Form H2065-D to the member. Refer to Appendix XVI, SASO Service Group, Service Code and Termination Code, for more information on SASO entries.

Refer to section 6300, Denials and Terminations, if the individual or applicant is denied eligibility for the STAR+PLUS HCBS program.

Refer to Section 6300.10, Other Reasons, for more information on denying an individual or applicant who chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program.

3515 Non-STAR+PLUS Individual Residing in a Nursing Facility

Revision 22-3; Effective Sept. 27, 2022

Program Support Unit (PSU) staff may receive a referral for a non-STAR+PLUS individual residing in a nursing facility (NF) requesting to transition to the community through the Money Follows the Person (MFP) process from:

  • the Community Care Services Eligibility (CCSE) case manager; or
  • the individual’s legally authorized representative (LAR).

PSU staff must complete the following activities within two business days of the referral:

  • create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record;
  • check the Community Services Interest List (CSIL) database to see if the member is on an Intellectual or Developmental Disability (IDD) 1915(c) Medicaid waiver interest list;
  • determine, according to the procedures below, if the member has either an open enrollment or services are temporarily suspended in an IDD 1915(c) Medicaid waiver:
    • check the Service Authorization System Online (SASO) to see if a service authorization record exists with an end date and termination code for:
      • Community Living Assistance and Support Services (CLASS) (Service Group (SG) 2);
      • Deaf Blind with Multiple Disabilities (DBMD) (SG 16);
      • Home and Community-based Services (HCS) (SG 21); or
      • Texas Home Living (TxHmL) (SG 22).
        • Note: A service authorization record containing an end date but no termination code indicates the 1915(c) Medicaid waiver program is temporarily suspended.

PSU staff complete the following activities within two business days of being notified the individual wishes to pursue a 1915(c) Medicaid waiver program:

  • notify the appropriate IDD waiver unit staff by email;
  • upload all applicable documents to the HEART case record following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
  • document and close the HEART case record.

PSU staff must complete the following activities within two business days of notification the individual has chosen to apply for the STAR+PLUS HCBS program:

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify if either Form H1200, Application for Assistance – Your Texas Benefits (PDF), has already been submitted for the nursing facility (NF) stay;
  • contact or attempt to contact the individual, or authorized representative (AR) by telephone to explain the Medicaid application process, the selection of a managed care organization (MCO) and the importance of promptly returning the application packet that PSU staff mail to the individual, if applicable;
  • mail an enrollment packet to the individual including:
  • inform the individual during the phone contact that their MCO selection can be changed at any time after the first month of service;
  • add the individual to the STAR+PLUS HCBS program interest list in the CSIL database; and
  • immediately release and assign the individual from the interest list in the CSIL database.

PSU staff must complete the following activities within 14 days of mailing the enrollment packet to the individual:

  • discuss with the individual the importance of immediately submitting Form H1200 if PSU staff have not received Form H1200 from the individual and TIERS does not have a record of submission;
  • discuss with the individual the importance of choosing an MCO, if the individual did not select one during the initial contact, explaining the MCO conducts the Medical Necessity and Level of Care (MN/LOC) Assessment and develops the initial individual service plan (ISP) to facilitate an eligibility determination for the STAR+PLUS HCBS program; and
  • document all contacts and attempted contacts in the HEART case record.

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

PSU staff must fax MEPD Form H1746-A, Referral Cover Sheet (PDF), and Form H1200 to the MEPD specialist within two business days of receipt of Form H1200. PSU staff must notate the individual is requesting to pursue the MFP process on From H1746-A.

PSU staff must deny the individual requesting the STAR+PLUS HCBS program if Form H1200 is not received within 45 days from the date PSU staff mailed Form H1200 to the individual. PSU must complete the following activities within two business days of the 45th day that PSU staff mailed Form H1200 to the individual:

PSU staff must default the individual to an MCO if a selection is not made within 30 days. PSU staff must complete the following activities within two business days from the date the individual makes an MCO selection, verbally or in writing, or from the date the member is defaulted to an MCO:

  • check SASO to determine if the applicant has a current MN/LOC Assessment;
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), indicating:
    • whether the applicant is on a 1915(c) Medicaid waiver program interest list;
    • if the applicant has a current medical necessity (MN) by entering the Resource Utilization Group (RUG) value; and
    • expiration date in Item 6;
  • upload Form H3676 to TxMedCentral, following the instructions in Appendix XXXIV; and
  • upload applicable documents to the HEART case record, following the instructions in Appendix XXXIII.

The MCO must complete the following activities within 45 days from receipt of Form H3676:

  • Conduct the MN/LOC Assessment if there is no valid Minimum Data Set (MDS) or complete its own MN/LOC Assessment in lieu of using the NF MDS. The MCO must complete the MN/LOC Assessment if there is no valid MDS.
    • A denied MN/LOC Assessment decision cannot be used to deny an applicant who has a valid MDS. The MDS and RUG value must be used for the MN determination.
    • A MN record must be located in SASO so the ISP registration does not suspend. The SASO MN record must match the ISP effective dates. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.
    • Develop the ISP using Form H1700-1, Individual Service Plan (PDF).

PSU staff must send an email to the Program Support Operations Review Team (PSORT) mailbox within two business days of an MCO failing to submit initial assessment information within the 45-day timeframe. The email sent to the PSORT mailbox must include:

  • an email subject line that reads: “STAR+PLUS HCBS Initial 45-Day XX [plan code] MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MCO non-compliance for Ann Smith would read “STAR+PLUS HCBS Initial 45-Day 9B MCO Non-Compliance for AS”;
  • individual or applicant’s name;
  • Social Security number (SSN) or Medicaid identification (ID) number;
  • date of birth (DOB);
  • name of the MCO and plan code;
  • the date information was due from the MCO;
  • a brief description of the delay and any MCO information received; and
  • attach any pertinent documents received from the MCO (e.g., Form H2067-MC).

3515.1 Non-STAR+PLUS Individual Transitioning to the Community with STAR+PLUS HCBS Program

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must collaborate as needed with involved parties throughout the STAR+PLUS Home and Community Based Services (HCBS) program eligibility determination process to help with problem resolution and to document any delays. PSU staff must track and document all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record until all STAR+PLUS HCBS program enrollment activities are complete.

The managed care organization (MCO) must upload the following information to the MCOHub within 45 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF), from PSU staff:

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet (PDF), to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days of receipt of the approved individual service plan (ISP) and Medical Necessity and Level of Care (MN/LOC) Assessment if Medicaid is pending. PSU staff must notate the individual is requesting to pursue the Money Follows the Person (MFP) process on Form H1746-A. The MEPD specialist notifies PSU staff upon completion of the evaluation for financial eligibility through the MEPD Communications Tool.

PSU staff must complete the following activities within two business days of receipt of all required eligibility documentation from the MCO and MEPD specialist, when applicable:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid eligibility;
    • an approved MN/LOC Assessment;
    • an ISP with:
      • at least one STAR+PLUS HCBS program service per ISP year; and
      • a cost within the individual's cost limit.
  • manually generate the initial Form H2065-D, Notification of Managed Care Program Services (PDF);
    • Note: refer to Form H2065-D instructions for additional information on field entries;
  • mail the initial Form H2065-D to the member;
  • upload the initial Form H2065-D to the MCOHub;
  • upload applicable documents to the HEART case record; and
  • document the HEART case record.

The MCO collaborates with the relocation specialist, nursing facility (NF), applicant and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC to the MCOHub within two business days of the discharge date being determined. PSU staff must upload Form H2067-MC to the MCOHub within two business days of being notified by any other entity of a different NF discharge date, asking which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to the MCOHub advising of the correct discharge date. The MCO must upload Form H2067-MC to the MCOHub within two business days of the date the applicant is discharging from the NF.

PSU staff must complete the following activities within five business days of being notified of the NF discharge:

  • manually or electronically generate the second Form H2065-D;
    • Note: refer to Form H2065-D instructions for additional information on field entries;
  • mail the second Form H2065-D to the member;
  • upload the second Form H2065-D on the MCOHub if manually generated;
  • fax or email Form H1746-A and Form H2065-D to the MEPD specialist for generation of a pending task in Texas Integrated Eligibility Redesign System (TIERS);
  • verify that NF records in the Service Authorization System Online (SASO) reflect the NF end date;
    • contact the Texas Health and Human Services Commission (HHSC) Long Term Care (LTC) Provider Claims Services at 512-438-2200 and select option 1 to request closure of the NF service authorization in SASO, if the NF end date has not processed within five business days from the date of discharge;
  • create one-day STAR+PLUS HCBS program service authorization record in SASO for the first day of the month in which an MFP applicant is discharged from the NF.
  • close the Community Services Interest List (CSIL) database record using the appropriate closure code;
  • for Medical Assistance Only (MAO) members, notify the Enrollment Resolution Services (ERS) Unit staff by email. The email to the ERS Unit staff must include the following:
    • an email subject line that reads “STAR+PLUS HCBS MFP Enrollment Request for XX [member’s first and last name initials].” For example, the email subject line for an MCO transfer for Ann Smith would be “STAR+PLUS HCBS MFP Enrollment Request for AS”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (MFP NF discharge);
    • medical necessity (MN) approval date;
    • individual service plan (ISP) receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment (date of NF discharge); and
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

Refer to section 6300, Denials and Terminations, if the individual or applicant is denied eligibility for the STAR+PLUS HCBS program.

Refer to section 6300.10, Other Reasons, for more information on denying an individual or applicant who chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program.

3520 Money Follows the Person Demonstration

Revision Notice 23-3; Effective Aug. 21, 2023

3521 Money Follows the Person Demonstration Introduction

Revision Notice 23-3; Effective Aug. 21, 2023

The Money Follows the Person Demonstration (MFPD) was implemented to eliminate barriers and enable Medicaid-eligible individuals to transition from nursing facilities (NFs) to the community and receive necessary long-term services and supports (LTSS) in the setting of the individual's choice. Participation in MFPD does not affect the type or amount of services received or how the individual receives the services. A member participating in MFPD receives the same services delivered to other STAR+PLUS Home and Community Based Services (HCBS) program members.

3522 Screening Criteria for Money Follows the Person Demonstration Eligibility

Revision Notice 23-3; Effective Aug. 21, 2023

The managed care organizations (MCO) must apply the following screening criteria to determine if an applicant is potentially eligible to participate in the Money Follows the Person Demonstration (MFPD). To be eligible for MFPD, the applicant must be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program and meet the following criteria:

  • reside continuously in an institutional setting, including days during a Medicare certified skilled nursing facility (SNF) stay following a stay in a Medicaid certified nursing facility (NF), for at least 60 days before  the STAR+PLUS HCBS eligibility date;
  • be enrolled in MFPD before leaving a Medicaid certified NF;
  • be Medicaid eligible under Title XIX of the Social Security Act;
  • be transitioning from an NF into a qualified residence that includes:
    • a home owned or leased by the applicant or the applicant's family;
    • an apartment with an individual lease that includes living, sleeping, bathing and cooking areas where the applicant or applicant’s family has domain;
    • Assisted Living (AL) apartment (Service Code 19);
    • Residential Care apartment (Service Code 19A); or
    • Adult Foster Care (AFC) home with no more than four unrelated individuals living in the home; and
  • agree to participate in the MFPD by completing Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation (PDF).

3522.1 Screening for 60-Day Qualifying Institutional Stay

Revision Notice 23-3; Effective Aug. 21, 2023

For purposes of the Money Follows the Person Demonstration (MFPD), an institutional setting is defined as a: 

  • Medicaid certified nursing facility (NF);
  • Medicaid certified skilled nursing facility (SNF); 
  • intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
  • state supported living center; or
  • hospital.

A continuous stay in a combination of the settings above may meet the 60-day qualifying institutional stay. 

Example: An MFPD applicant resides continuously in a Medicaid certified NF for 30 days, in a hospital for 15 days and then re-enters the NF for another 15 days. This applicant would meet the 60-day institutional residency requirement for MFPD.

The MFPD applicant does not have to live in the Medicaid certified NF or other institution for 60 days at the time they indicate a desire to transition to the community. The MFPD applicant meets the screening criteria if it appears likely they will live in a Medicaid certified NF or other institution for at least 60 days before the discharge date from the NF.

3522.2 MCO Reporting of 60-Day Qualifying Institutional Stay

Revision Notice 23-3; Effective Aug. 21, 2023

The managed care organization (MCO) must notify Program Support Unit (PSU) staff of a Money Follows the Person Demonstration (MFPD) applicant using Form H2067-MC, Managed Care Programs Communication. The MCO must check box 10, MFP Demonstration Consent Obtained, and enter the institutional admission and discharge dates in the Comments section. PSU staff are not required to verify if the applicant has met the 60-day institutional stay requirement.

3523 Enrollment in Money Follows the Person Demonstration

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must designate a member as being enrolled in the Money Follows the Person Demonstration (MFPD) by modifying Service Authorization System Online (SASO) records. Refer to Section 9480, MFPD for STAR+PLUS HCBS Program Applicant, for more information on PSU staff actions in SASO for MFPD members.

PSU staff must select the fund type "19MFP-Money Follows the Person" in the SASO Service Authorization record for the first individual service plan (ISP) participation period in MFPD. PSU staff must remove this fund type after the MFPD entitlement period or if the member withdraws from MFPD. Refer to Section 3524, Money Follows the Person Demonstration Entitlement Period Tracking, for more information on SASO entries once the enrollment period has ended.

The member may withdraw from MFPD at any time by informing the managed care organization (MCO). The MCO must upload Form H2067-MC, Managed Care Program Communications (PDF), to TxMedCentral to notify PSU staff of the member’s withdrawal from MFPD. Although MFPD eligibility may end upon withdrawal from MFPD, the member continues to receive STAR+PLUS Home and Community Based Services (HCBS) program services if the member continues to meet all STAR+PLUS HCBS eligibility criteria.

3524 Money Follows the Person Demonstration 365-Day Entitlement Period Tracking

Revision Notice 23-3; Effective Aug. 21, 2023

A Money Follows the Person Demonstration (MFPD) member is entitled to 365 days of participation in MFPD. Time spent in an institutional setting does not count toward the 365-day entitlement period. The managed care organization (MCO) tracks the enrollment period to ensure the MFPD member receives the full 365 days.

The entitlement period begins the date the MFPD member enrolls in the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO must notify Program Support Unit (PSU) staff once the MFPD period has ended by uploading Form H2067-MC, Managed Care Program Communications (PDF), to TxMedCentral. The MCO must notate the MFPD entitlement period start and end dates in the Comments section of Form H2067-MC. 

Example: The member chose to participate in MFPD and was enrolled in the STAR+PLUS HCBS program, effective June 1, 2019, with an initial individual service plan (ISP) effective June 1, 2019, through May 31, 2020.

  • If there are no institutional stays during the initial ISP period, the MFPD entitlement period ends when the ISP period ends on May 31, 2020.
  • If the MFPD member enters an institution for 10 days in April 2020, the MFPD entitlement period is suspended during the period of institutionalization. The MFPD enrollment period resumes when the members return to the community and continues until the end of the 365-day entitlement period. In this example, the MFPD entitlement period ends on June 10, 2020, after the ISP end date of May 31, 2020.
  • If the MFPD member is authorized for a new MFPD service during the initial ISP period and there are no institutional stays, the MFPD entitlement period would still end on May 31, 2020.

PSU staff must complete the following activities within two business days of notification that the MFPD entitlement period has ended:

  • remove the Fund Type "19MFP-Money Follows the Person" from the Service Authorization System Online (SASO) Service Authorization record that reflects the MFPD entitlement period;  
  • notify the MFPD reporting coordinator by email. The email to the MFPD reporting coordinator must include: 
    • an email subject line that reads: “MFPD Entitlement Period End [MM/YYYY]." For example, the email subject line for an MFPD member with an entitlement period ending Nov. 30, 2022, would be “MFPD Entitlement Period Ending 11/2022.”; and
    • Form H2067-MC received from the MCO notating MFPD entitlement period information;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and 
  • document and close the HEART case record. 

3530 High or Complex Needs Members

Revision 18-0; Effective September 4, 2018

3531 Designation of High Needs Members

Revision 18-0; Effective September 4, 2018

The Uniform Managed Care Contract (UMCC), Attachments A and B-1, Section 8.1.12, specifies the managed care organization (MCO) must develop and maintain a system and procedures for identifying members with special health care needs (MSHCN), including people with disabilities or chronic or complex medical and behavioral health conditions and children with special health care needs (CSHCN).

The MCO must contact members pre-screened by the Texas Health and Human Services Commission (HHSC) Administrative Services contractor as MSHCN to determine whether the members meet the MCO's MSHCN assessment criteria, and to determine whether the members require special services. The MCO must provide information to the HHSC Administrative Services contractor identifying members who the MCO has assessed to be MSHCN, including any members pre-screened by the HHSC Administrative Services contractor and confirmed by the MCO as MSHCN. The information must be provided in a format and on a time line to be specified by HHSC in the Uniform Managed Care Manual (UMCM), and updated with newly identified MSHCN by the 10th day of each month. In the event that an MSHCN changes MCOs, the MCO must provide the receiving contractor information concerning the results of the MCO's assessment of that member's needs to prevent duplication of those activities.

CSHCN means a child (or children) who:

  • ranges in age from birth up to age 19;
  • has a serious ongoing illness, a complex chronic condition or a disability that has lasted or is anticipated to last at least 12 continuous months or more;
  • has an illness, condition or disability that results (or without treatment would be expected to result) in limitation of function, activities or social roles in comparison with accepted pediatric age-related milestones in the general areas of physical, cognitive, emotional, and/or social growth and/or development;
  • requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel; and
  • has a need for health and/or health-related services at a level significantly above the usual for the child's age.

MSHCN includes a CSHCN and any adult member who:

  • has a serious ongoing illness, a chronic or complex condition, or a disability that has lasted or is anticipated to last for a significant period of time; and
  • requires regular, ongoing therapeutic intervention and evaluation by appropriately trained health care personnel.

3532 Determination of High Needs Status for Ongoing Members

Revision 18-0; Effective September 4, 2018

If, during the individual service plan (ISP) period, the managed care organization (MCO) determines the member's subsequent ISP may have the potential to exceed the cost limit, that member is considered to have high needs status. Once designated as having a high needs status, the MCO must initiate in the ninth month of the ISP period plans to bring the ISP at or under the cost limit.

If it appears the subsequent ISP will exceed the cost limit and efforts to explore other alternatives to protect health and safety are not successful, the MCO initiates a request for a staffing with the Texas Health and Human Services Commission (HHSC) to determine whether a request for the use of General Revenue (GR) funds is appropriate.

3600, Ongoing Service Coordination

Revision 18-0; Effective September 4, 2018

Based on the needs of the STAR+PLUS Home and Community Based Services (HCBS) program member, the managed care organization's (MCO's) ongoing service coordination responsibilities could include:

  • revising the individual service plan (ISP) as necessary to meet the needs of the member, responding to service plan change requests and responding to requests for additional services such as adaptive aids, emergency response services (ERS), respite or requests for service suspension;
  • coordinating and consulting with MCO-contracted providers regarding delivery of services;
  • reminding the member to complete and return Medicaid renewal eligibility documents sent by Program Support Unit (PSU) staff or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • monitoring services delivered to members, evaluating the adequacy and appropriateness of the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program, and documenting monitoring activities;
  • assisting the member in accessing and using community, Medicare, family and other third-party resources (TPR);
  • assisting with crisis intervention; and
  • responding to situations of potential denial of an active member whose ISP costs exceed the individual's assessed cost limit, including requesting a re-evaluation of need, meeting with the interdisciplinary team and administrative staff, and coordinating other services before termination of the STAR+PLUS HCBS program.

3610 Revising the Individual Service Plan

Revision 23-2; Effective May 15, 2023

It may be necessary for the managed care organization (MCO) to revise the individual service plan (ISP) within the ISP period due to: 

  • changes in the needs of the member; 
  • changes in the services offered; or 
  • emergency situations. 

The MCO must document revisions to the ISP on Form H1700-1, Individual Service Plan, and retains it in the member’s case record. The MCO must not submit the revised ISP to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) or upload it to TxMedCentral.
 

3611 MCO Required Notifications from the Provider

Revision 18-0; Effective September 4, 2018

The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

  • the member leaves the service area for more than 30 days;
  • the member has been legally confined in an institutional setting. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
  • the member is not financially eligible for Medicaid benefits;
  • providers have refused to serve the member on the basis of a reasonable expectation that the member's medical and nursing needs cannot be met adequately in the member's residence;
  • the member or someone in the member's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery;
  • the member fails to pay his or her qualified income trust (QIT) copayment;
  • the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider;
  • the member or someone in the member's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider; or
  • the member requests that services end.

3611.1 Immediate Suspension or Reduction of Services

Revision 18-0; Effective September 4, 2018

If the member or someone in the member's place of residence exhibits reckless behavior that may result in imminent danger to the health and safety of service providers, the managed care organization (MCO) and MCO contracted provider are required to make an immediate referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services (DFPS) and/or the police and suspend services. The MCO must immediately provide written notice of temporary suspension of service to the member, and the right of appeal to a state fair hearing must be explained to the member. The written notification must specify the reason for denial or suspension, the effective date, the regulatory reference and the right of appeal.

The provider must verbally inform the MCO by the following business day of the reason for the immediate suspension, and follow up with written notification to the MCO within two business days of verbal notification. The MCO must make a face-to-face visit to initiate efforts to resolve the situation. If the temporary suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the STAR+PLUS Home and Community Based Services (HCBS) program provider may continue providing services to assist in the resolution of the crisis. If the crisis is not satisfactorily resolved, the MCO follows the established denial procedures. Services do not continue during the appeal process.

3620 Reassessment

Revision 18-0; Effective September 4, 2018

3621 Reassessment Procedures

Revision 22-3; Effective Sept. 27, 2022

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is entered into the Service Authorization System Online (SASO) annually. PSU staff must complete the following activities within 45 days of the ISP expiration date:

  • check the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to determine if the managed care organization (MCO) has submitted:
    • Form H1700-1, Individual Service Plan, containing the following:
      • at least one unmet need;
      • is within the cost limit;
      • personal assistance services (PAS) and emergency response services (ERS) can be included for a member who is part of the medical assistance only (MAO) Medicaid eligibility group;
      • PAS and ERS must be authorized through Community First Choice (CFC) for a Supplemental Security Income (SSI) member. An SSI or SSI-related (e.g., Medicaid for Disabled Adult Children (DAC) or Pickle Medicaid) member receiving CFC should not have the PAS or ERS boxes checked on Form H1700-1;
      • protective supervision as a component of PAS can only be authorized through the STAR+PLUS Home and Community Based Services (HCBS) program and is not a benefit of CFC. Therefore, if an MCO authorizes protective supervision for any STAR+PLUS HCBS program member (MAO Medicaid or SSI), the MCO must check the protective supervision box on Form H1700-1 for this service;
      • Note: PSU staff must upload Form H2067-MC to TxMedCentral advising the MCO to correct Form H1700-1 if the ERS and PAS checkboxes are selected in error for an SSI or SSI-related member receiving CFC;
    • an approved Medical Necessity and Level of Care (MN/LOC) Assessment;
  • confirm ongoing Medicaid eligibility the Texas Integrated Eligibility Redesign System (TIERS);
  • confirm ongoing Medicaid eligibility;
  • verify the Service Authorization System Online (SASO) service authorization records are accurate;
    • refer to Section 9200, Reassessment Service Authorization, for additional information on SASO record verifications.

PSU staff must ensure the member's ISP is entered into the SASO annually. PSU staff must manually enter the ISP into SASO within five business days, but prior to the ISP end date, if the MCO is not able to submit the Form H1700-1 electronically through the TMHP LTCOP.

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

3622 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 STAR+PLUS Home and Community Based Services (HCBS) program requirements. PSU staff must complete the following activities for an approved STAR+PLUS HCBS program reassessment within five business days of verification that the member continues to meet all STAR+PLUS HCBS program 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;
  • 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 XXXIII, STAR+PLUS HEART Naming Conventions; and
  • document and close the HEART case record.

Refer to Section 6000, Denials and Terminations, if the member does not meet STAR+PLUS HCBS program 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.

3623 Eligibility Date on Form H2065-D

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must adhere to the following policy when establishing the eligibility date for STAR+PLUS Home and Community Based Services (HCBS) program cases on Form H2065-D, Notification of Managed Care Program Services. The effective date varies. The possible scenarios include:

  • upgrades and interest list releases;
  • members transitioning out of children's programs; and
  • transfers from a nursing facility (NF) using the Money Follows the Person (MFP).

3623.1 Upgrades and Interest List Releases

Revision Notice 23-3; Effective Aug. 21, 2023

The start of care (SOC) date for a STAR+PLUS Home and Community Based Services (HCBS) program applicant released from the interest list, or a member requesting or being processed for an upgrade is based on the following:

  • notification or verification of Medicaid eligibility;
  • date the Medical Necessity and Level of Care (MN/LOC) Assessment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) is approved; and
  • date the managed care organization (MCO) submits the individual service plan (ISP) in the TMHP LTCOP or submits to PSU staff in TxMedCentral.

The SOC for STAR+PLUS HCBS program is the first day of the month following the individual or member meeting all eligibility criteria. The eligibility and ISP effective date on Form H2065-D, Notification of Managed Care Program Services, is the first day of that month if the date the form is being generated is on the first day of the month. The eligibility and ISP effective date on Form H2065-D is the first date of the following month if the date the form is being generated falls between the second and the last day of the month. 

Note: A valid MN does not exceed 120 days from the date of TMHP approval. Program Support Unit (PSU) staff must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting the MCO submit a new initial MN/LOC Assessment in the TMHP LTCOP if the MN exceeds 120 days. PSU staff must follow the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, when uploading Form H2067-MC to TxMedCentral.
 

3623.2 Members Transitioning Out of Children's Programs

Revision 18-0; Effective September 4, 2018

The eligibility and the individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transitioning out of the programs below is the first day of the month following their 21st birthday:

  • Medically Dependent Children Program (MDCP)
  • Texas Health Steps (THSteps) Comprehensive Care Program (CCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC)

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP through STAR Health until age 22. In this scenario, the eligibility and ISP effective date is the first day of the month following their 22nd birthday.

3623.3 MFP Initiative Nursing Facility Releases

Revision 18-0; Effective September 4, 2018

The ISP effective date on Form H2065-D, Notification of Managed Care Program Services, for members transferring from nursing facilities (NFs) to the STAR+PLUS Home and Community Based Services (HCBS) program through the Money Follows the Person (MFP) process is the date of discharge. The STAR+PLUS HCBS eligibility date on Form H2065-D for members transferring from NFs to the STAR+PLUS HCBS program through the MFP process, is the date used on the initial Form H2065-D. Service Authorization System Online (SASO) registration for MFP releases from NFs must occur as follows:

  • NF Service Group 1 SASO registrations must be closed the day before the discharge.
  • STAR+PLUS HCBS program service group (SG) 19 SASO registration covers the entire individual service plan (ISP) period. The ISP effective date on Form H2065-D is the date of discharge.

4100, Adult Foster Care

4110 Adult Foster Care Introduction

Revision 19-13; Effective November 5, 2019

Adult foster care (AFC) provides 24-hour living arrangements and personal care services (PCS) and supports for persons who, because of physical or behavioral conditions, are unable to live independently. Services and supports may include assistance and/or supervision with daily living, including meal preparation, housekeeping, companion services, personal care, nursing tasks and the provision of, or arrangement for, transportation. The STAR+PLUS Home and Community Based Services (HCBS) program applicant or member who chooses AFC must reside with a contracted STAR+PLUS HCBS program AFC home provider that meets the minimum standards and licensure requirements found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

AFC home providers must be contracted either directly with the member’s managed care organization (MCO) or with an AFC provider agency contracted with the member’s MCO. The individual qualified to provide AFC (AFC home provider) must be the primary caregiver. AFC home providers must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. AFC home providers may serve up to three adult residents in a qualified AFC home without being licensed as a personal care home or assisted living facility (ALF), and may be the AFC home provider’s home or the STAR+PLUS HCBS program member’s home. AFC home providers with four or more residents, which are also contracted with the Texas Health and Human Services Commission (HHSC), are required to have a Type C Personal Care Home license. AFC homes with four to eight AFC residents must be licensed as an ALF, with limitations on the number of residents at each level who may reside in the home. The three levels of eligibility for AFC are explained in Section 4133, Adult Foster Care Classification Levels. ALF licensure requirements are found in Title 26 Texas Administrative Code (TAC) Chapter 553, §553.41.

Any reference to “resident” includes members receiving services in the STAR+PLUS HCBS program AFC or private pay individuals. AFC home providers may serve a combination of STAR+PLUS HCBS program members and private pay individuals in a qualified or licensed AFC home as long as the AFC home provider continues to meet the minimum standards specified in Appendix XXIV, and additional other standards may be specified by the MCO.

When the AFC home provider moves in with the STAR+PLUS HCBS program member receiving AFC in the member’s home, the AFC home enrollment requirements indicated with an asterisk in Appendix XXIV may be waived at the discretion of the MCO or the MCO-contracted AFC provider agency, as appropriate. Other minimum standards, excluding home safety requirements, may be waived at the discretion of the MCO, or upon the recommendation by the MCO-contracted AFC provider agency if the MCO-contracted AFC provider agency has completed a home assessment and concluded the member’s needs can be appropriately met through the STAR+PLUS HCBS program and AFC specific services. Such conclusions must be documented by the MCO-contracted AFC provider agency and approved by the MCO.

The MCO is responsible for ensuring the AFC member receives all necessary AFC services, including the authorization of other needed services and nursing tasks.

STAR+PLUS HCBS program AFC members are required to pay for their own room and board (R&B) charges and, if able, contribute to the cost of AFC services through a copayment to the AFC home provider. The only time the R&B charge is not required is when the AFC home provider moves in with the member and the member's home becomes the AFC home. R&B arrangements must be documented in the member’s case file by the MCO or by the MCO-contracted AFC provider agency.

If an AFC home is contracted with HHSC to provide services to a member receiving AFC through HHSC, the MCO or the MCO-contracted provider agency may request a copy of the AFC home and AFC home provider qualification documents from HHSC, if applicable. These documents contain HHSC findings regarding the qualifications of the AFC home and AFC home provider.

4111 Adult Foster Care Purpose

Revision 19-13; Effective November 5, 2019

The purpose of the STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) is to promote the availability of appropriate services in a home-like environment for members who are aging and who have disabilities to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of a member.

The STAR+PLUS HCBS program requires each AFC member to have enough living space to guarantee his or her privacy, dignity and independence.

4112 Reserved for Future Use

Revision 24-1; Effective Feb. 22, 2024

4113 Adult Foster Care Services

Revision 19-13; Effective November 5, 2019

The adult foster care (AFC) home provider must provide services, supports and supervision, as needed, around the clock in an AFC home that has either been qualified based on the minimum standards or licensed by the Texas Health and Human Services Commission (HHSC) (for homes serving four or more residents). Services may include personal assistance services (PAS).

A STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) member may not receive STAR+PLUS HCBS program PAS while the member is a resident in a STAR+PLUS HCBS program AFC home. Form H6516, Community First Choice Assessment or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and any addendums to Form H2060, are completed by the managed care organization (MCO) to determine the needed tasks for completion by the AFC home provider. The MCO must provide a copy of the required PAS tasks to the AFC home provider and to the MCO-contracted AFC provider agency, if applicable:

  • transportation;
  • supervision;
  • meal preparation; and
  • housekeeping.

AFC services, except for 24-hour supervision that is provided to all STAR+PLUS HCBS program AFC members, are provided on an "as needed" basis, with the flexibility to meet the member's needs in the least restrictive way possible. For example, STAR+PLUS HCBS program AFC members may not need assistance with medication or help with transportation, but the services are available to all STAR+PLUS HCBS program members in AFC homes. PAS tasks must be provided, as identified on Form H6516, Form H2060 and any addendums to Form H2060. The AFC home provider may provide more services for the member than are authorized, as the changing needs of the member may warrant, but may not reduce or discontinue services without prior consultation with the MCO.

STAR+PLUS HCBS program members, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to non-emergency medical transportation is available to members through the Medical Transportation Program (MTP).

4120 Minimum Standards for All AFC Homes and Providers

Revision 19-13; Effective November 5, 2019

All adult foster care (AFC) homes and AFC home providers must be qualified initially and annually thereafter in accordance with the minimum standards outlined in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

4121 AFC Homes with Four or More Residents and Members

Revision 19-13; Effective November 5, 2019

An adult foster care (AFC) home provider must obtain an assisted living (AL) license if the AFC home provider wants to serve four or more private pay residents and/or members. The AFC home provider may apply for an AL license from the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The license must be renewed annually and requires an annual fee. Licensing standards for various types of AL facilities are found in Title 26 Texas Administrative Code (TAC) Chapter 553, §553.41.

The AFC home provider must submit a copy of the AL license to the managed care organization (MCO) or MCO-contracted AFC provider agency before being credentialed and upon renewal. The AFC home provider must report to the MCO or MCO-contracted AFC provider agency any problem(s) identified by the HHSC Regulatory Services Division. AFC home providers must meet all applicable requirements in the minimum standards for AFC. AFC home providers with an AL license must serve no more than a total of eight adult residents in a small group home.

AFC homes of four or more residents, without an HHSC contract, are also subject to the following two sets of regulations:

  • Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers; and
  • Licensing Standards for Assisted Living Facilities, found in Title 26 TAC, Chapter 553, §553.41.

The stricter requirements apply when requirements of the two sets of regulations conflict. For example, an AFC home licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of members currently residing in the facility.

If the MCO uses a contracted AFC provider agency, the contracted AFC provider agency must provide copies of any licenses for AFC homes of four or more residents when the MCO requests them.

4122 Small Homes for One to Three Residents and Members

Revision 19-13; Effective November 5, 2019

An adult foster care (AFC) home provider who serves up to three residents, including STAR+PLUS Home and Community Based Services (HCBS) program members, may be a member's relative, excluding the spouse. While these small homes do not require licensure, AFC homes and AFC home providers must meet the standards found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers. As outlined in Section 4110, Adult Foster Care Introduction, if the AFC home provider moves into the AFC member's home, AFC home requirements in Appendix XXIV may be waived at the discretion of the managed care organization (MCO) or MCO-contracted AFC provider agency.

4123 MCO Responsibilities

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) responsibilities include:

  • providing information to interested applicants about potential adult foster care (AFC) homes and coordinating visits to the homes;
  • developing an individual service plan (ISP);
  • acting as coordinator of the interdisciplinary team (IDT);
  • authorizing AFC services;
  • evaluating and coordinating services for the member;
  • notifying the member, AFC home provider and AFC provider agency, if applicable, of room and board (R&B) charges and copayment amounts, as outlined in Section 3236, Copayment and Room and Board;
  • processing changes and conducting annual reassessments for the member;
  • completing an assessment to ensure the potential or existing member’s needs can be met in a particular home;
  • recruiting, contracting and credentialing AFC homes and home providers;
  • processing AFC home and home provider applications;
  • orienting and training AFC home providers;
  • approving private pay residents;
  • ensuring initial and ongoing compliance with AFC minimum standards;
  • conducting annual requalification reviews of the AFC home and home provider;
  • conducting administrative reviews; and
  • processing AFC provider payments.

An MCO may also choose to contract with an AFC provider agency to facilitate AFC home and home provider management on behalf of the MCO. When this occurs, the contracted AFC provider agency is responsible for provisions stipulated in its contract with the MCO. However, the MCO retains overall responsibility for all requirements related to AFC service delivery and oversight of the MCO contracted AFC provider agency and the member.

4130 Adult Foster Care Eligibility

Revision 19-13; Effective November 5, 2019

To be eligible for adult foster care (AFC), applicants and members must meet basic eligibility requirements for STAR+PLUS Home and Community Based Services (HCBS) program services as well as specific requirements related to AFC. Basic eligibility requirements for the STAR+PLUS HCBS program can be found in Section 3230, Financial Eligibility, and Section 3240, STAR+PLUS HCBS Program Requirements. AFC applicants or members are identified for STAR+PLUS HCBS program AFC based on their assessed needs for care. Refer to Section 4133, Adult Foster Care Classification Levels, for additional information.

4131 AFC Intake, Assessment and Response to Request for Services

Revision 19-13; Effective November 5, 2019

Adult foster care (AFC) is appropriate for individuals who, because of physical, mental or behavioral conditions, are unable to live independently and who need and desire the support and security of family living. AFC may be appropriate for individuals who are:

  • seeking alternatives to facility-based care; or
  • interested in leaving institutional care but are unable to resume independent living.

When discussing AFC as an option for applicants or members, the managed care organization (MCO) or MCO-contracted AFC provider must explain the room and board (R&B) requirements and ensure the applicant or member understands that he or she must pay a portion of the monthly income for R&B. If the AFC home provider moves into the member’s home, payment for R&B charges does not apply. The MCO must also explain that some members residing in an AFC home are additionally required to contribute to the cost of their AFC services by paying a copayment, regardless of whether the AFC home is the member's home. Refer to Section 4152, Room and Board and Copayment Requirements, for additional information.

4132 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

4133 Adult Foster Care Classification Levels

Revision 19-13; Effective November 5, 2019

Classification (payment levels) for adult foster care (AFC) members are used for identification of potential AFC applicant or member appropriateness and are based on the member’s assessed needs for care, as determined through the required face-to-face assessments for STAR+PLUS Home and Community Based Services (HCBS) program services and the individual service plan (ISP) completed by the managed care organization (MCO) service coordinator. Determine and document whether an applicant or member is appropriate for AFC based on the applicant’s or member’s condition and behavior. Develop an ISP appropriate to the applicant’s or member’s needs and specific to a given AFC home provider, taking into consideration the AFC home provider’s capabilities. The MCO-contracted AFC provider agency, if applicable, would be involved in a determination of AFC home provider capabilities.

4133.1 Levels of Adult Foster Care Members

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) will use the Medical Necessity and Level of Care (MN/LOC) Assessment, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums. The MCO service coordinator determines a member’s classification level for adult foster care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) (transferring, walking, dressing, eating, toileting, bathing), and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member.

Below are the classification levels of a member’s daily assistance or supervision requirements.

Level I AFC Member

A member who needs assistance with identified needs including a minimum of:

  • one ADL and behavior(s) that occur at least once a week; or
  • two ADLs.

Level II AFC Member

A member who needs assistance with identified needs including a minimum of:

  • two ADLs and behavior(s) that occur at least once a week; or
  • three ADLs.

Level III AFC Members

A member who needs assistance with identified needs including a minimum of:

  • three ADLs and behavior(s) that occur at least once a week; or
  • four ADLs.

4133.2 AFC Homes Corresponding to AFC Member Levels

Revision 19-13; Effective November 5, 2019

The adult foster care (AFC) home provider must be able to meet the member’s needs in the AFC setting in conjunction with the STAR+PLUS Home and Community Based Services (HCBS) program and other available supports. If the member’s needs for care exceed the capability of the AFC home provider, the managed care organization (MCO) service coordinator must reassess the member and offer alternate care options.

The AFC home provider who is a licensed registered nurse (RN) and the AFC home provider RN substitute must provide proof of current licensure to the MCO or contracted provider agency (if applicable) initially and annually thereafter.

The MCO RN service coordinator will complete the Medical Necessity and Level of Care (MN/LOC) Assessment, both initially and annually. AFC home providers with STAR+PLUS HCBS program members may not care for more than one totally dependent AFC resident. The MCO RN service coordinator must respond to a request for a change in services within the individual service plan (ISP) year.

Health maintenance activities (HMAs) are tasks which may be exempt from RN delegation based on the MCO RN assessment. HMAs may enable the member to remain in an independent living environment and go beyond activities of daily living (ADLs) because of the higher skill level required to perform them (as found in the Texas Board of Nursing (BON) rules in Title 22 Texas Administrative Code (TAC) §225.4(8)).

For members residing in Level I, Level II and Level III AFC homes not operated by an RN, the skilled nursing needs must be:

  • identified by the MCO service coordinator as HMAs;
  • purchased as nursing services on the ISP;
  • provided by Medicare, Medicaid home health or other resource;
  • met by a nurse at a Day Activity and Health Services (DAHS) facility; or
  • a combination of the above options.

For members residing in Level I, Level II and Level III AFC homes operated by an RN, the skilled nursing needs must be:

  • identified by the MCO service coordinator as HMAs;
  • met by the AFC home provider nurse or nurse substitute;
  • provided by Medicare, Medicaid home health or other resource; or
  • a combination of the above options.

AFC members receiving nursing services and residing with an RN who is the AFC home provider are not eligible to receive DAHS.

4134 Adult Protective Services and Adult Foster Care

Revision 19-13; Effective November 5, 2019

This section provides details regarding when Adult Protective Services (APS) staff request adult foster care (AFC) as a resource for individuals who may benefit from AFC.

4134.1 Placement of APS Clients in AFC

Revision 19-13; Effective November 5, 2019

Adult Protective Services (APS) may want to move an adult foster care (AFC) individual into an AFC home where a STAR+PLUS Home and Community Based Services (HCBS) program member resides. The managed care organization (MCO) must approve and ensure the APS individual is appropriate and document this in the MCO case record. This includes determining the:

  • APS individual's medical and behavioral health needs are met;
  • capacity of the AFC home provider to meet the APS individual's needs; and
  • compatibility of service delivery to the APS individual with the delivery of services to existing AFC members who may reside in the AFC home.

If the MCO determines the APS individual's placement is not appropriate, the APS individual may not move into the AFC home and the APS worker must make other living arrangements.

4134.2 APS Investigations of AFC Providers

Revision 19-13; Effective November 5, 2019

Any time managed care organization (MCO) staff of an MCO-contracted adult foster care (AFC) provider agency suspect abuse, neglect or exploitation (ANE) of an AFC member in an unlicensed AFC home, the staff must report it immediately to Adult Protective Services (APS). Reports of ANE in a licensed AFC home must be made to the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The MCO-contracted AFC provider agency must also notify the MCO.

If reports of ANE taking place in an unlicensed AFC home are made to APS by other parties, the MCO or MCO-contracted AFC provider agency staff may not be notified of member allegations against an AFC provider until after the allegations have been validated. However, APS staff may ask the MCO or MCO-contracted provider agency to assist with the delivery of alternative services during the investigation if the alleged mistreatment poses an immediate threat to the safety of the member or other AFC residents.

The MCO handles disenrollment and corrective actions against the AFC home provider, as appropriate. HHSC takes necessary licensure actions for licensed AFC homes. If HHSC terminates the licensure of an AFC home and the MCO is unable to find a suitable alternative residence for the member, the member is referred to APS for assistance in moving from the AFC home.

A member in an unlicensed AFC home who has the capacity to consent may decide not to move from the AFC home, even though the allegation has been validated. In this instance, the member's AFC services will be denied, payments to the home will terminate and an MCO-contracted provider agency will withdraw from supporting ongoing management of the home. However, the member may continue to reside in the unlicensed AFC home by making private pay arrangements at that home.

If a member residing in an unlicensed AFC home, who does not appear to have the capacity to consent, refuses to move from an unlicensed AFC home in which an individual identified as the perpetrator in a case of validated ANE lives and is in a state of ANE, the MCO must make a referral to APS. The MCO-contracted AFC provider agency staff must send a referral to the MCO and APS if the agency staff identify this situation.

If the substantiated allegation of ANE is in a licensed AFC home, the perpetrator must be removed from the AFC home and the license holder must submit to HHSC a plan for the protection of the health and safety of all residents. The resident will not be required to move.

4135 Private Pay Individuals in AFC

Revision 19-13; Effective November 5, 2019

Some adult foster care (AFC) home providers may wish to take private pay individuals. The AFC home provider must contact the managed care organization (MCO) when considering the admission of a private pay individual before he or she is accepted in the AFC home. The purpose of the approval is to determine the:

  • appropriateness of AFC for the private pay individual based on the individual’s condition and behavior;
  • capacity of the AFC home to meet the private pay individual’s needs; and
  • compatibility of service delivery to the private pay individual and the delivery of services to AFC members.

If the MCO determines placement in an AFC home is inappropriate, the AFC home provider cannot accept the private pay individual. Any issues regarding placements must be resolved by the MCO.

4140 AFC MCO Procedures

Revision 19-13; Effective November 5, 2019

This section provides details for a managed care organization (MCO) when determining an applicant's eligibility for adult foster care (AFC) and for developing the applicant’s or member’s individual service plan (ISP).

4141 Eligibility Determination

Revision 19-13; Effective November 5, 2019

To determine eligibility for Adult Foster Care (AFC), the managed care organization (MCO) must determine the applicant or member meets all criteria for the STAR+PLUS Home and Community Based Services (HCBS) program and completes an assessment to determine the applicant’s or member’s classification level. If the AFC placement is with an individual AFC home provider contracted with the MCO, the MCO must also ensure the applicant or member has an agreement with an enrolled AFC home provider, and the applicant or member and AFC home or home provider are appropriately matched per the classification and needs of the applicant or member before the MCO pays for AFC services. If an MCO contracts with an AFC provider agency to perform AFC management services, the MCO-contracted provider agency may perform activities related to the qualification of the home and the home provider before the MCO pays for AFC services. Refer to Section 4133, Adult Foster Care Classification Levels, for additional information.

4142 Service Planning

Revision 19-13; Effective November 5, 2019

The member’s plan of care (POC) must address functional, medical, social and emotional needs and how the needs will be met by the adult foster care (AFC) home provider. The managed care organization (MCO) must assess whether other resources in the community should be used to meet specialized needs of the member. Use of those resources must be documented in the member’s POC.

The MCO must complete Form H6516, Community First Choice Assessment or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, to document the specific personal assistance tasks with which the AFC home provider must assist the member. The AFC home provider may provide more services for the member than are identified on Form H2060 as the changing needs of the member may warrant but may not reduce or discontinue services without consultation with the MCO or MCO-contracted AFC provider agency.

Upon approval for AFC, the MCO determines if the member has any special needs that require additional monitoring in the AFC home. The MCO must document any special needs or interventions in the case record on Form 2327, Individual/Member and Provider Agreement. Use the "Other Special Arrangements" space under the "Miscellaneous Arrangements" section.

The MCO or MCO-contracted AFC provider agency contacts the member and the AFC home provider to arrange for the initial visit and a negotiated move-in date for the member or AFC home provider. If there are health concerns regarding the member, the MCO nurse may be consulted and a recommendation may be made for the member to have a physical or medical exam before moving into the AFC home. The MCO coordinates with the interdisciplinary team (IDT) and the MCO-contracted AFC home provider, if applicable, regarding the AFC member’s care.

4150 Finalizing the Member’s Plan of Care

Revision 19-13; Effective November 5, 2019

On or before the date the member begins to receive adult foster care (AFC) services, a face-to-face meeting with the member and the AFC home provider is required to discuss the member's plan of care (POC) and to complete Form 2327, Individual/Member and Provider Agreement. The interdisciplinary team (IDT), including the staff of the managed care organization (MCO)-contracted AFC provider, as applicable, and the member's family, authorized representative (AR) or guardian may be included in the meeting. The meeting should preferably take place in the AFC home.

The MCO must discuss the member's POC with the member and family, AR or guardian and reach understanding with them about how the AFC home provider will meet the member’s needs. This discussion should ensure the member and family, AR or guardian that the AFC home provider is adequately prepared to provide services to the member and that adjustments occur smoothly. The MCO must document the POC and any special needs of the member or special agreements between the member and AFC home provider on Form 2327.

If the applicant or member is already residing in the AFC home, Form 2327 must be completed by the MCO service coordinator face-to-face with the applicant or member and AFC home provider or provider agency, if applicable, before the MCO pays for AFC services initially and upon annual reassessment.

4151 Member and AFC Home Provider Agreement

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) documents the service arrangements and the agreement of the room and board payment (R&B) charge on Form 2327, Individual/Member and Provider Agreement.

The MCO or the MCO-contracted adult foster care (AFC) provider agency reviews all of the information on the agreement with the member, family, authorized representative (AR) or guardian and the AFC home provider. All conditions of the agreement and the following topics must be covered in the discussion:

  • A full description of the care needs of the member and frequency of services needed.
  • The need for, and frequency of, supervision.
  • The beginning and ending date on Form 2327.
  • A detailed description of the rights and responsibilities of the member and the AFC home provider.
  • An explanation of the member's and AFC home provider's right to privacy and confidentiality.
  • The monthly dollar amount the member agrees to pay the AFC home provider for R&B, as documented on Form 2327.
  • The arrangements for a trust fund if the STAR+PLUS Home and Community Based Services (HCBS) program member requests such service from the AFC home provider.
  • An inventory of the AFC member’s personal belongings.
  • The names, addresses and telephone numbers of the persons to be notified in an emergency, including the member's physician, family members and/or AR or guardian.
  • Any special habits and needs of the member and any special arrangements or agreements between the member and the AFC home provider.
  • Any additional training needs of the AFC home provider and methods to obtain that training.
  • The rights and responsibilities of both the member and the AFC home provider for notifying the MCO, MCO-contracted AFC provider agency, as applicable, of problems such as illnesses, adverse medication reactions, hospitalizations, acts of violence, accidents or complaints about abuse, neglect or exploitation (ANE). The Texas Health and Human Services Commission (HHSC) Managed Care Compliance and Operations (MCCO) Unit staff must be notified if the member, MCO-contracted provider agency or AFC home provider have a complaint or issue regarding the health and safety of the member.
  • Other conditions that reflect changes in the member's condition that might affect the appropriateness of AFC services.

The MCO or MCO-contracted provider agency must fully discuss with the AFC home provider the potential for transition issues arising after the member moves into the AFC home or when the AFC home provider moves into the member’s home. The discussion should include notification procedures and suitable actions to be taken to address issues and resolve problems, and the impact of a new living situation on family and other residents in the home.

The member and the AFC home provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement. Form 2327 must be completed and signed before authorizing and reauthorizing AFC. Any significant changes to the terms of the agreement must be reported by the AFC home provider within five business days. Any incidents, as referenced in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers, must be reported by the AFC home provider to the MCO service coordinator assigned to the member, and the MCO-contracted AFC provider agency, as applicable, within 24 hours of the occurrence.

4152 Room and Board Charges and Copayment Requirements

Revision 19-13; Effective November 5, 2019

Room and board (R&B) charges and copayment are applicable to adult foster care (AFC) members as described in Section 3236, Copayment and Room and Board. If the AFC service is provided in the member’s own home, the member is not required to pay R&B charges. It is the responsibility of the managed care organization (MCO) to ensure the member and the MCO-contracted AFC provider agency, as applicable, are notified in writing on Form 2327, Individual/Member and Provider Agreement, when the R&B charge is waived. It is the MCO-contracted AFC provider agency’s responsibility to notify the AFC home provider when the R&B charge is waived. The copayment amount, if applicable to the member, may be waived.

The R&B charge, as applicable, is entered on Form H2065-D, Notification of Managed Care Program Services, and Form 2327. The member does not pay R&B if the AFC home provider moves in with the member into the member’s home. The MCO or MCO-contracted AFC provider agency must ensure the member and AFC home provider understand that the R&B arrangement with the AFC home provider is separate from the MCO payment for AFC services. The member pays the AFC home provider the R&B charge listed on Form 2327 and Form H2065-D. If the member is moving into the AFC home mid-month, the amount of R&B for the month is prorated and the member and AFC home provider will be advised of the prorated amount.

If a copayment is applicable, the AFC member's copayment amount is listed on Form H2065-D, which is sent to the member by Program Support Unit (PSU) staff and uploaded to TxMedCentral in the managed care organization’s (MCO’s) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Form H2065-D is used to report to the member the amount of his or her copayment for the first month of authorized service and subsequent months. The MCO furnishes a copy of Form H2065-D to the AFC home provider.

When the R&B amounts and/or copayment change, the MCO must notify the AFC home provider and the member of the new amount before the change, as described in Section 3239, Copayment Changes. The member must pay the R&B charge and copayment amount by the eighth day of the month. If the member does not pay the required fees, he or she may not be eligible for STAR+PLUS Home and Community Based Services (HCBS) program AFC services.

The STAR+PLUS HCBS program AFC home provider must collect the copayment amount from the member. The AFC home provider must keep receipts for all copayments collected. The AFC home provider must deduct the copayment amount authorized on Form H2065-D from reimbursement claims submitted to the MCO or advise the MCO-contracted AFC provider agency of the amount collected. If a STAR+PLUS HCBS program AFC member does not pay the R&B or copayment amount, the MCO or MCO-contracted AFC provider agency must investigate the member's failure to pay, including contacting the member to learn the reason the fees were not paid. Even if there is a legitimate reason, such as the member's income check has not been received by the eighth day of the month, the member is still under obligation to pay the fees. Grievances between the member and the AFC home provider are not legitimate reasons for the member to withhold payments due. Such grievances must be resolved through the intervention of Texas Health and Human Services Commission (HHSC) Managed Care Compliance and Operations (MCCO) Unit staff and the MCO.

If the member refuses to pay the fees or there is no legitimate reason for failing to pay, the MCO shall write a letter to the member or authorized representative (AR) explaining the consequences of continued refusal to pay. If the member does not pay his or her required fees within 30 days of the due date, the MCO can terminate AFC services to the member. If STAR+PLUS HCBS program AFC is being delivered in the AFC home provider’s residence, the member can then be evicted from the home, according to local eviction ordinances and procedures.

4153 Trust Funds

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) must offer money management assistance by the adult foster care (AFC) home provider to the member and document when the member either accepted or refused the assistance. If the member expresses an interest in money management, the MCO documents the expressed interest on Form H2067-MC, Managed Care Programs Communication, and sends the form to the AFC home provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.

The AFC home provider must maintain trust fund records. The AFC home provider must:

  • have written permission from the member, his or her guardian, power of attorney or applicable individual to handle the member’s personal financial affairs;
  • keep member trust accounts separate from the AFC home provider's operating accounts. The separate account must be identified "Trustee (name of the STAR+PLUS Home and Community Based Services (HCBS) program AFC home provider), Member's Trust Fund Account." If the AFC home provider maintains a trust fund, the AFC home provider must:
    • deposit the member's monthly income into the account; and
    • write a check for the room and board (R&B) charge and copayment amount out of the trust fund account into the AFC home provider's operating account. Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and R&B allowance into the trust fund account;
  • make the member trust fund records available for review by the MCO or AFC home provider agency during work hours without prior notice;
  • not charge the member for services the AFC home provider is expected to provide for the member;
  • not charge the member for banking service costs if the member’s trust fund is in a pooled account;
  • obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the AFC home provider is handling. The AFC home provider must include at least the following in the records:
    • member's name;
    • identification of member's representative payee or responsible party;
    • admission date;
    • member's earned interest; and
    • transactions – the AFC home provider may choose one of the following options:
      • maintain records of the date and amount of each deposit and withdrawal, the name of the person who accepted the withdrawn funds and the balance after each transaction. The member must sign each withdrawal. If the member is unable to sign when funds are being withdrawn from his or her trust funds, the transactions or receipt must be signed by a witness other than the AFC home provider or employee or contractor of the provider; or
      • maintain signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his or her name, a witness other than the AFC home provider or employee or contractor of the provider must sign the transaction or receipt; and
  • distribute the interest earned on any pooled interest banking account in one of the following options:
    • prorated to each member on an actual interest earned basis; or
    • prorated to each member based on his or her end-of-quarter balance.

The following information must be included on the receipt for all money that is received or deposited in the member’s trust fund:

  • member's name;
  • date the money was received;
  • source of the money;
  • amount received; and
  • amount returned to the member, if any.

All records pertaining to the member's trust fund must be kept in the manner designated above, and available for monitoring without notice.

4154 Hospital Leave

Revision 19-13; Effective November 5, 2019

If a member is receiving adult foster care (AFC) services in an AFC home which is not the member’s home, the member may be required to reserve his or her space during hospital stays by paying the daily bedhold charge, if the provider requires such a charge, which is the negotiated daily rate the managed care organization (MCO) pays the AFC home provider or MCO-contracted provider agency. The AFC home provider does not bill the MCO for the days the STAR+PLUS Home and Community Based Services (HCBS) program AFC member is hospitalized. The AFC member's bedhold charge constitutes the entire payment to the AFC home provider or MCO-contracted AFC provider agency when an AFC member is hospitalized.

During the initial home visit, the MCO or MCO-contracted AFC provider agency review the information regarding the AFC member's responsibility to pay a bedhold charge when away from the home and document this on Form 2327, Individual/Member and Provider Agreement. Hospital leave does not apply when the AFC home provider moves into the member’s home.

4160 Monitoring Quality of Care

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) service coordinator will monitor the quality of care and services provided to meet the needs of the STAR+PLUS Home and Community Based Services (HCBS) program members receiving adult foster care (AFC) services. The MCO service coordinator will appropriately address any issues identified to protect the health and safety of the member.

During regular monitoring visits, the MCO service coordinator must contact the MCO management and MCO-contracted AFC provider agency, if applicable, if the AFC home provider is not meeting the member's needs or the home provider requires additional support or training to meet the member’s needs. The AFC member's physical and medical condition must be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness.

Form 2327, Individual/Member and Provider Agreement (see No. 1 under Miscellaneous Arrangements), is used to document special monitoring schedules and other resources used in the plan of care (POC). When the AFC home provider moves in with the AFC member, it is the MCO's responsibility to ensure the AFC member's needs are being met, and there are no health and safety concerns. If concerns are reported or identified, the AFC member's rights must be protected and adjustments to the POC made accordingly.

4170 Reserved for Future Use

Revision 24-1; Effective Feb. 22, 2023

4180 Annual Reassessment of the AFC Member

Revision 19-13; Effective November 5, 2019

In addition to the regular reassessment for the STAR+PLUS Home and Community Based Services (HCBS) program, which includes the managed care organization (MCO) service coordinator completing the Medical Necessity and Level of Care (MN/LOC) Assessment, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums, and the individual service plan (ISP) documents, the MCO or MCO-contracted adult foster care (AFC) provider agency must also continue to meet all eligibility requirements and complete Form 2327, Individual/Member and Provider Agreement.

4200, Assisted Living Services

4210 Assisted Living Services Introduction

Revision 19-13; Effective November 5, 2019

This section applies to the STAR+PLUS Home and Community Based Services (HCBS) program. Assisted living (AL) services provide a 24-hour living arrangement for persons who, because of physical or mental limitation, are unable to continue independent functioning in their own homes. Services are provided in personal care facilities licensed by the Texas Health and Human Services Commission (HHSC). STAR+PLUS HCBS program members are responsible for their room and board (R&B) charges and, if applicable, copayments for AL.

The purpose of AL services is to promote the availability of appropriate services for elderly and disabled persons in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of the member. The personal care facility must provide each member a separate living unit to guarantee their privacy, dignity and independence.

4211 Housing Options in Licensed Personal Care Facilities

Revision 19-13; Effective November 5, 2019

An assisted living (AL) apartment may be an efficiency or one- or two-bedroom apartment, and each apartment must have a private bath and cooking facilities. An AL non-apartment setting is defined as a licensed personal care facility which has living units that do not meet the definition of an AL apartment, may be double occupancy, and must be:

  • freestanding; and
  • licensed for 16 or fewer beds.

STAR+PLUS Home and Community Based Services (HCBS) program AL contracts specify whether the facility has contracted to provide services under the housing options of AL or AL non-apartment. The provider may not deliver STAR+PLUS HCBS program services in a housing option for which the provider does not have a contract to deliver services. If a provider wishes to maintain both AL (single occupancy) and AL apartments (double occupancy) in one facility, the member’s contract must specify that information.

If the AL provider wishes to limit the types of apartments in the facility available to STAR+PLUS HCBS program members, the provider must specify these limitations in the contract, either at the time of signature or by amendment. The apartments in question must meet all qualifications as specified in this section. If there are no such specifications in the contract, all types of apartments in the facility must be available to STAR+PLUS HCBS program members.

If the provider limits the type of apartment available for STAR+PLUS HCBS program members and there is no apartment of that size available, they can refuse to accept any STAR+PLUS HCBS program member, based on not having space available. This would apply both for a member wanting to move into the facility from the outside, or to a private pay member currently in the facility who is becoming a STAR+PLUS HCBS program member. The member would then have the option of reviewing other available assisted living facilities (ALFs) in the area or adult foster care (AFC) homes.

"Freestanding" is defined as not physically connected to a licensed nursing facility, hospital or another licensed personal care facility, unless the total licensed capacity of both personal care facilities does not exceed 16 beds. At a minimum, a covered walkway between buildings is required for physical connection.

At the member's request, portable kitchen units may be removed from the living area.

4211.1 Single Occupancy Apartments

Revision 19-13; Effective November 5, 2019

An assisted living (AL) apartment setting is defined as an apartment for single occupancy that is a private space with individual living and sleeping areas, a kitchen, bathroom and adequate storage space, as specified in the following:

  • The apartment must have a minimum of 220 square feet, not including the bathroom. Apartments in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.
  • The kitchen is an area equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.
  • The bathroom must be a separate room in the individual's living area with a toilet, sink and an accessible bath.
  • The bedroom must be single occupancy except when double occupancy is requested by the individual.

4211.2 Double Occupancy Apartments

Revision 19-13; Effective November 5, 2019

An assisted living (AL) apartment must be a double occupancy apartment with a connected bedroom, kitchen and bathroom area that provides a minimum of 350 square feet of space per individual, and meets the following specifications:

  • Indoor common areas used by STAR+PLUS Home and Community Based Services (HCBS) program members may be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.
  • The kitchen must be equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.

4220 Description of Services

Revision 19-13; Effective November 5, 2019

The assisted living facility (ALF) must provide 24-hour care in a personal care facility licensed by the Texas Health and Human Services Commission (HHSC). Services include:

  • home management;
  • transportation and escort;
  • 24-hour supervision;
  • meal services; and
  • social and recreational activities.

Personal care tasks must be provided on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, as identified on the individual service plan (ISP) and approved by the MCO. A registered nurse (RN) must perform the medication administration assessment.

The AL provider is responsible through its licensure requirements for providing the administration of medications, which is the direct administration of all medications, or the assistance with or supervision of medication. This includes injections, if needed. Only a licensed RN can give injections. The personal care facility may provide more services for the member than are identified in the ISP, but not fewer services.

4221 Requirements Related to Assisted Living Facility

Revision 19-13; Effective November 5, 2019

STAR+PLUS Home and Community Based Services (HCBS) program members who wish to reside in a personal care facility must reside in a licensed assisted living facility (ALF) which is contracted with the managed care organization (MCO) to provide STAR+PLUS HCBS program services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services (PCS) to four or more persons who are unrelated to the owner. The member is required to pay room and board (R&B) charges, and possibly a copayment amount based on income in the ALF setting. Refer to Section 3230, Financial Eligibility, for detailed information.

4222 Reserved for Future Use

Revision 23-2; Effective May 15, 2023
 

4223 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

4224 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

4230 Other Services Available to Members

Revision 19-13; Effective November 5, 2019

Each of the following services are provided according to the needs of the member, as authorized on the individual service plan (ISP), as a STAR+PLUS Home and Community Based Services (HCBS) program service and not included in the assisted living facility (ALF) daily rate:

  • adaptive aids and medical supplies;
  • minor home modifications (MHMs);
  • occupational therapy (OT);
  • physical therapy (PT);
  • speech therapy (ST); or
  • nursing services.

The managed care organization (MCO) makes referrals for the services and coordinates delivery.

The use of self-administered oxygen is allowed in a STAR+PLUS HCBS program ALF. Since oxygen is a flammable substance, precautions must be taken to ensure that smoking is prohibited in or around the area where the oxygen is being self-administered.

4240 Copayment and Room and Board Requirements

Revision 19-13; Effective November 5, 2019

The member must pay the required fees to be eligible for assisted living facility (ALF) services. Refusal to pay the required fees can result in termination of services.

The facility must designate a due date for room and board (R&B) charges and the copayment amount in writing. The due date must be during the same month the R&B charges and copayment amount are applied. The facility must collect the entire R&B charges and copayment amount on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire R&B charge and copayment amount on or before the first business day thereafter.

4240.1 Room and Board Charges Requirements

Revision 19-13; Effective November 5, 2019

All members must pay the room and board (R&B) charges to be eligible for assisted living (AL). R&B charges cannot be waived, but an assisted living facility (ALF) may choose to accept an applicant or member for a lower amount. STAR+PLUS Home and Community Based Services (HCBS) program policy does not direct the facility to accept or reject the applicant or member. The R&B charge is based on the Supplemental Security Income (SSI) federal benefit rate (FBR), minus a personal needs allowance of $85. This is a set rate unless there is a change in the FBR. Generally, the FBR only changes annually on January 1. The R&B charge is adjusted accordingly based on that change. For the initial month of entry, the monthly rate is divided by the number of days in that month, then multiplied by the number of days the member is in the ALF. The managed care organization (MCO) must notify the applicant or member of the initial amount of R&B charge to pay and the ongoing amount of R&B charge to pay.

4240.2 Copayment Requirements

Revision 19-13; Effective November 5, 2019

The amount of copayment the member is required to pay is determined by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist through use of the MEPD copayment worksheet. The MEPD specialist makes the determination of the copayment amount available. The managed care organization (MCO) communicates the amount of copayment each member is to pay the provider.

Program Support Unit (PSU) staff mail Form H2065-D, Notification of Managed Care Program Services, to the member and upload a copy of Form H2065-D to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Once received through TxMedCentral, the MCO sends a copy to the assisted living facility (ALF), detailing the first month's copayment amount and the subsequent months' amounts.

4241 Personal Leave

Revision 19-13; Effective November 5, 2019

The member is entitled to 14 days of personal leave from the assisted living facility (ALF) each year. The member is responsible for the room and board (R&B) charge and copayment amount for personal leave days.

A day of personal leave is defined as 24 continuous hours. STAR+PLUS Home and Community Based Services (HCBS) program assisted living (AL) members must sign out when leaving the facility and sign in upon returning. The sign-in log must have at minimum the following information:

  • name of the person;
  • time and date of departure;
  • destination;
  • emergency contact; and
  • type of leave (for example, personal leave or hospital leave).

4242 Nursing Services for Members in an ALF

Revision 19-13; Effective November 5, 2019

If a member is residing in an assisted living facility (ALF), all the administration of medications, including injections, is provided by the nurse. It is possible that a member residing in an ALF does not need any nursing tasks that are to be delivered by the STAR+PLUS Home and Community Based Services (HCBS) program. Examples of when this may occur include when the member's only nursing need is for medication administration that is provided by the nurse or when the member is receiving nursing services through Medicare.

4243 Response to ALF Member Condition Change

Revision 19-13; Effective November 5, 2019

If the member experiences a change in health or condition related to the amount and type of care the member requires, the managed care organization (MCO), in conjunction with the other members of the interdisciplinary team (IDT), the provider, and the member or authorized representative (AR) may explore other means to serve the member adequately in his or her current setting. The use of Day Activity and Health Services (DAHS) for daily nursing tasks or the direct provision of nursing by provider nurses may be explored as alternatives that would avoid disrupting the member's living arrangement. Nursing tasks cannot be delegated in an assisted living facility (ALF).

If a member exhibits behavior or degradation of mental health that threatens the health or safety of himself or herself or other residents in the facility, or the member’s needs exceed the licensed capacity of the facility, the ALF provider must take appropriate action and notify the MCO orally by the next business day. The provider must confirm the verbal report in writing within seven days. The MCO must take appropriate actions based on the oral notification to assess the member's continued eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program. Refer to Section 4251, Facility Reporting and Notification Requirements.

If a STAR+PLUS HCBS program member living in an assisted living (AL) apartment becomes a safety hazard to himself or herself or others due to the member’s operation of the stove or cooking unit in the apartment, the AL provider can disconnect the unit and must notify the MCO by the next business day. The MCO must investigate the situation and document any recent or previous incident which indicates a threat to the health and safety of the member or other residents in the facility. The MCO, in cooperation with the IDT, the AL provider, and the member's family or AR, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The MCO’s decision is documented on Form H2067-MC, Managed Care Programs Communication, which is sent to the AL provider within three business days of the IDT meeting.

4244 Hospital and Nursing Facility Stays

Revision 19-13; Effective November 5, 2019

Hospital Stays

To reserve bedhold during hospital stays, the member must pay the daily room and board (R&B) charge.

The facility's bedhold charge or the negotiated bedhold charge for reserving a member's space during hospital stays may not exceed the maximum amount established by the managed care organization (MCO).

The facility does not bill the MCO for days the member is hospitalized. The member's R&B charge, used as a bedhold charge, constitutes the entire payment to the facility when a member is hospitalized.

The facility must notify the MCO on Form H2067-MC, Managed Care Programs Communication, when the member has been in the hospital for 30 days. The MCO monitors the member's situation every month up to four months to determine if the stay will become permanent. The MCO will notify Program Support Unit (PSU) staff by uploading Form H2067-MC to TxMedCentral in the MCOs SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. If the member stays in the hospital longer than four months, the member is systemically disenrolled.

A hospital includes a rehabilitation hospital or a rehabilitation floor or wing of a medical hospital.

Nursing Facility Stays

For issues related to nursing facility (NF) payment, see the Medicaid for the Elderly and People with Disabilities HandbookSection H-1700, Deduction for Home Maintenance.

The MCO must follow the Uniform Managed Care Contract (UMCC), Attachment B.1, Section 8.3.2.6, Nursing Facilities, related to NF stays.

4245 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

4250 Standards for Operation

Revision 19-13; Effective November 5, 2019

Assisted living facilities (ALFs) must:

  • provide each member the choice of a private or semi-private room;
  • reserve space for up to three days from the agreed-upon entry date for each referred member before requesting another referral;
  • designate a separate bedroom area for members in dual facilities where nursing facility (NF) members are co-housed in the facility; and
  • accept all managed care organization (MCO) referrals if space is available.

The only reason a STAR+PLUS Home and Community Based Services (HCBS) program ALF provider could refuse to accept a referral is if the member's condition makes the member inappropriate for the facility according to the facility's personal care licensure.

Having a communicable disease does not necessarily make a member inappropriate for placement in an ALF setting. Transmission of communicable diseases and conditions can be prevented through the implementation of infection control procedures, including universal precautions. Licensure standards for personal care facilities require facilities to have infection control policy and procedures, including universal precautions, in operation to safeguard employees and residents from these and other diseases and contagious conditions. If transmission of the condition or disease cannot be controlled, the member cannot be placed in a STAR+PLUS HCBS program ALF setting.

To receive ALF services under the STAR+PLUS HCBS program, the applicant must first be determined eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff will fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, to complete the Medicaid eligibility determination.

The MCO discusses residential options with the member, allowing the member to choose his or her preference. If an ALF is chosen, a verbal referral is made to the provider as an alert that bedhold is needed. The starting date for services is a negotiated date between the MCO, the member and the ALF provider. The initial copayment amount is computed based on the starting date. Form H1700-1, Individual Service Plan (Pg. 1), and applicable attachments are sent as follow-up, along with a copy of Form H2065-D, Notification of Managed Care Program Services, which authorizes the provider to deliver STAR+PLUS HCBS program services, and Form H2067-MC, Managed Care Programs Communication, confirming the negotiated service initiation date.

Note: Appropriate action must be taken if the facility finds that a member threatens the health and safety of himself or herself or other residents in the facility. If a stove or cooking unit needs to be disconnected, the MCO service coordinator, in cooperation with the interdisciplinary team (IDT), makes this decision. The IDT must also include the MCO, the ALF provider and the member's family or authorized representative (AR), if any.

The ALF provider can disconnect the stove or cooking unit if the member exhibits a behavior that threatens the health and safety of himself or herself or other residents in the facility. The ALF must inform the MCO service coordinator of the disconnection by the next business day after it occurs. The MCO investigates the situation and documents any recent or previous incidents that indicate a threat to the health or safety of the member or other residents in the facility. If the decision is made to approve a disconnection, the MCO service coordinator documents actions on Form H2067-MC that is sent to the ALF provider within three days.

Note: The ALF must make oral notification no later than the first business day after the due date. Within five business days of the MCO receiving notification from the provider that the member has failed to pay the room and board (R&B) charge or copayment amount, the MCO uploads Form H2067-MC to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. Form H2067-MC serves as notification to PSU staff of the member's failure to pay the R&B charge and copayment amount. Within three business days, PSU staff must mail the member Form H2065-D stating services will be terminated if the member fails to pay the R&B charge and/or copayment amount within 30 days of the date on Form H2065-D.

If a STAR+PLUS HCBS program member does not pay the R&B charge and copayment within 30 days of the date on Form H2065-D, the MCO contacts the member to learn the reason the fees were not paid. Even if there is a legitimate reason (such as the member's income check has not been received by the 10th day of the month) for the non-payment of the required fees, the member is still under obligation to pay the fees.

If the member simply refuses to pay the fees, or there is no legitimate reason for his or her failing to pay, the MCO writes a letter to the member, with copies to the ALF manager and to the member's AR, if applicable, explaining the possible consequences of continued refusal to pay.

The MCO is responsible for working with the member during this time period to assure alternative services will be available. If the member refuses to leave the facility when his or her services are terminated, the ALF must follow its written eviction procedures.

In addition, ALFs must:

  • conduct a health assessment with the member within three days of admission to the facility;
  • provide each member with training in the emergency or disaster procedures and evacuation plan within three days from the date of service initiation. The training must be documented in the member's record. The facility must also document all training and orientation provided to members and facility staff;
  • provide services according to the member's health assessment or individual service plan (ISP);
  • document the member's daily activity and service delivery on the daily census record;
  • obtain written approval from the MCO before discharging a member, except when MCO staff cannot be reached and the member threatens the health or safety of himself or herself or other residents in the facility;
  • help the member to prepare for transfer or discharge;
  • provide a minimum of four social and recreational activities per week;
  • collect payment from the member according to R&B and copayment policies. If payment is not made by the 10th day of the month, the facility must send notice to the member by the 11th day of the same month;
  • allow the member to manage his or her finances and/or trust funds. The facility must provide assistance to the member in managing his or her finances only if the member requests assistance in writing;
  • refund, within five business days after the member has been discharged, the full balance of the member's personal funds that the facility deposited in an account. This applies to copayment amounts and trust funds; and
  • inform the member verbally and in writing, before or at the time of admission, of bedhold policies for hospital or nursing facility (NF) stays, personal leave, eviction procedures, all available services in the facility, and charges for services not paid by the MCO and/or not included in the facility's basic daily rate.

Examples of charges not paid by the MCO could be the destruction of facility property or any additional charges, such as pet deposits. Items not required to be provided by the ALF provider through the ALF licensing standards (for example, returned check fees, service deposits) may be charged to the member if listed in the admission agreement. The MCO may contact the Texas Health and Human Services Commission (HHSC) Regulatory Services Division regarding any questionable items charged to the member.

4251 Facility Reporting and Notification Requirements

Revision 19-13; Effective November 5, 2019

The facility must verbally report to the managed care organization (MCO) the following occurrences pertinent to member services by the next business day after they occur. These occurrences must be followed up in writing within five business days after they occur and may lead to MCO intervention and/or termination of services, including but not limited to:

  • significant changes in the member's health and/or condition, such as:
    • the member enters a hospital, nursing facility (NF), state school or state hospital;
    • death of a member; or
    • serious occurrences or emergencies involving the member or facility staff; and
  • changes based on member actions, such as the member:
    • is discharged because he or she threatens the health or safety of himself or herself or other residents in the facility;
    • leaves the state;
    • requests that services end;
    • refuses to comply with the individual service plan (ISP);
    • fails to pay the copayment amount;
    • exceeds personal leave days; and
    • requests to move to another facility.

If a member exhibits behavior that threatens the health or safety of himself or herself or other residents in the facility, or the member’s needs exceed the licensed capability of the facility, the provider's written notice must explain the situation and the reasons the member is no longer appropriate for the services. With the concurrence of the MCO, discharge can be as soon as practical when:

  • the health and safety of residents in the facility would be endangered if the member would remain in the facility; or
  • the member's medical needs escalate beyond the capability of the facility to meet his or her needs. For example, the member's mental condition may deteriorate to the point that involuntary commitment to a mental institution is necessary.

4252 Member Documentation

Revision 19-13; Effective November 5, 2019

The facility must maintain records for each member that include at least the following information:

  • health assessment;
  • serious occurrences or emergencies involving members or facility staff;
  • incidents when a member threatens the health and safety of himself or herself or other residents in the facility;
  • documentation when the member has used 10 personal leave days during the member's current individual service plan effective period;
  • documentation when the member's needs exceed the licensed capability of the personal care facility;
  • termination of services to a member;
  • hospitalization of a member;
  • death of a member; and
  • documentation when a member requests to move to another facility.

4260 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

4270 Copayment and Trust Fund Records

Revision 19-13; Effective November 5, 2019

 

4271 Copayment

Revision 19-13; Effective November 5, 2019

The facility must keep receipts for all copayments collected. The facility must deduct the copayment amount as documented on Form H2065-D, Notification of Managed Care Program Services.

The facility must maintain a current member copayment ledger system that reflects all charges and all payments made by, or on behalf of, each member. This system must reflect all copayment charges, payments and balances; it must be maintained in accordance with generally accepted accounting principles. If a member’s copayment amount is paid from a trust fund, the facility still must prepare a receipt.

The ledger must also reflect room and board (R&B) charges and payments, and the member must be given a receipt for the R&B payments.

4272 Trust Fund Records or Written Receipts

Revision 19-13; Effective November 5, 2019

The facility must maintain trust fund records based on recognized fiscal and accounting principles and have written permission from the member to handle his or her personal financial affairs.

Members must be informed that:

  • funds will be commingled with the funds of other members if the facility will handle the member's trust fund; and
  • the facility may review trust fund records of all members whose funds are commingled.

If the member is unable to sign or initial the transaction, or if the member signs his or her name with a mark (x), the transaction must be signed by a witness. The facility must:

  • keep the member's trust fund accounts separate from the facility's operating accounts. The separate account must be identified "Trustee, (name of facility), Member's Trust Fund Account";
  • make the member's trust records available for review by the facility during work hours without prior notice;
  • not charge the member for services that the facility is expected to provide for the member;
  • refrain from charging the member for banking service costs if the member's trust fund is in a pooled account;
  • obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the facility is handling; and
  • include at least the following in the trust fund records:
    • member's name;
    • identification of member's representative payee or responsible party;
    • transactions; and
    • member's earned interest.

The facility may choose one of the following options:

  • records of the date and amount of each deposit and withdrawal;
  • the name of the person who accepted the withdrawn funds; and
  • the balance after each transaction.

Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his or her trust fund, the transaction or receipt must be signed by a witness or signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his or her name, a witness must sign the transaction or receipt.

Distribute the interest earned on any pooled interest banking account in one of the following options:

  • prorated to each member on an actual interest earned basis;
  • prorated to each member based on his or her end-of-quarter balance; or
  • prorated to each member's account monthly if interest is paid on a monthly basis.

If the facility earns interest on any pooled interest account, the interest earned must be prorated to each member's account. Deposit entries should be documented as "interest" in the member's ledger. All transactions must be posted by the middle of the following month. The facility may:

  • keep a running balance; or
  • compute a balance at the end of the month.

If the facility maintains a trust fund, the facility staff must:

  • give the member a receipt for the money deposited into the trust fund;
  • deposit the member's monthly income into the account; and
  • write a check for the room and board (R&B) charges and copayment amounts out of the trust fund account into the facility operating account.

Facility staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and R&B allowance into the trust fund account. If the member writes a check to be deposited into his or her trust fund account and there are insufficient funds to cover the check, the facility can charge the member only the actual insufficient funds fee charged by the bank.

There is no requirement that the deposit into the trust fund be made on the same date the money is received. However, the facility must ensure that the deposit slip or bank statement reflects the same amount recorded on the receipt.

4273 Records and Receipts

Revision 19-13; Effective November 5, 2019

The facility must ensure that records include written receipts for all purchases made by or for members. A receipt is a written or computer-generated, signed record of payment prepared at the time of payment. If the payment is in person, the written or computer-generated receipt must be signed and contemporaneous with the payment. If the payment is by mail, a statement at the end of the month satisfies the requirement for a written receipt and a bill for the next month. If a single receipt is written for different items, the receipt must clearly describe what the receipt covers.

The record or receipt must include the:

  • name of the member;
  • date the money was received;
  • coverage period;
  • purpose of the payment;
  • amount received;
  • source of the money;
  • amount returned, if any; and
  • signature of the facility representative.

The facility is required to have both a trust fund ledger and a copayment ledger. A current member copayment ledger system must be maintained that reflects all charges and all payments made by, or on behalf of, each member. This system must reflect all copayment charges, payments and balances, and be maintained in accordance with generally accepted accounting principles.

The facility must maintain both receipts for monies received from members and bank deposit slips showing the money deposited. These amounts must correspond to amounts recorded in the member's trust fund ledger. This system must be maintained in accordance with generally accepted accounting principles.

Vendor withdrawal records must be maintained, regardless of how facility staff account for trust fund transactions (withdrawals on a ledger, cash envelope or individual checkbook register). They must retain receipts for any payment out of a trust fund account that is more than $1.00. The receipt, cash register tape or sales statement is documentation of who actually received the money that was withdrawn from the trust fund account, and that the money was spent as authorized. Any unused money returned to the trust fund custodian must be redeposited to the member's trust fund account and appropriately documented. The prerequisites that allow withdrawal from the member's trust fund are:

  • the purchase must be authorized by and for the benefit of the member;
  • the cost must be reasonable; and
  • facility staff do not profit from the transaction. For example, purchasing items in bulk and selling them at a higher price, or the member authorized the purchase of a TV, stereo or refrigerator and staff are using it.

4274 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

4275 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

4276 Payment of Copayment and Room and Board from Trust Fund

Revision 19-13; Effective November 5, 2019

It is an acceptable and recommended practice to deposit the member's income into the trust fund account and then pay the room and board (R&B) charge and copayment amount from the trust fund account. In this way, the member's monthly payments can be traced to the trust fund. When the R&B charge and copayment amount are paid from the trust fund account, the corresponding member's account receivable ledger must show proper credit to the member's account.

Long-term Payments

For long-term payments, facility staff must obtain a signed statement from the member or responsible party authorizing long-term payments on the member’s behalf. Examples of long-term payments include insurance premiums, church tithe and cable TV. If the facility:

  • has a signed statement from the member authorizing the facility to pay long-term payments on the member’s behalf, they do not need a monthly receipt from the vendor; or
  • does not obtain a signed statement from the member, responsible party or authorized representative (AR) authorizing it to pay the monthly payment on the member's behalf, the facility must have a vendor receipt that includes all items previously identified.

Daily Withdrawals for Minor Purchases or Petty Cash Withdrawals

Members usually require small amounts of money to meet their daily needs for items such as soft drinks, snacks, etc. It is often difficult to keep supporting documents for all such minor purchases.

The member's signature or authorization for a cash withdrawal must be on the member ledger, the cash envelope or on a receipt.

Bulk Purchases

Bulk purchase of the same items may be made by the facility. In this case, the member's signature and the amount of the purchase must be on the member ledger or a receipt.

4277 Member Authorization

Revision 19-13; Effective November 5, 2019

If the member is unable to sign or initial the transaction, or if the member signs his or her name with a mark (X), the transaction must be signed by a witness. A witness is anyone other than the:

  • facility employee who is responsible for managing the trust fund accounts;
  • supervisor of the employee who manages the trust fund account; or
  • person who is receiving payment for services to the member.

4300, Respite Care Services

Revision 19-13; Effective November 5, 2019

Respite care services in the STAR+PLUS Home and Community Based Services (HCBS) program are available on an emergency or short-term basis to relieve those persons normally providing unpaid care for a STAR+PLUS HCBS program member unable to care for himself or herself.

4310 Service Coordination Duties Related to Respite Care

Revision 19-13; Effective November 5, 2019

To be eligible for respite care services, the member must live in his or her own home or with relatives or other individuals. The member may not live in an adult foster care (AFC) or assisted living (AL) setting.

The respite care provider must not be a primary caregiver, whether or not the respite care provider is related to the member and must not live with the STAR+PLUS Home and Community Based Services (HCBS) program member for whom respite care is needed. If the member's primary caregiver is the paid attendant who also provides uncompensated care, in-home respite care may be provided only during those hours the primary caregiver would be providing uncompensated care to the member. If the primary caregiver is the paid attendant and will be absent during hours for which the primary caregiver is normally paid, it is the employer of record who has the obligation to provide a substitute attendant during this period.

Respite care services are intended to relieve the primary caregiver during emergency or planned short-term periods. Respite care services must be authorized on the individual service plan (ISP) before the services can be delivered. The respite care rate for out-of-home settings includes payment for room and board (R&B) charges. There are no member R&B charges or copayment amounts for respite care services in out-of-home settings.

The managed care organization (MCO) service coordinator is responsible for documenting the respite care services needed by the member. For example, a member needs respite care services every Friday afternoon so the primary caregiver can attend class, or a member's primary caregiver has three four-day trips planned during the ISP year, or a primary caregiver has a history of emergency hospitalizations. The MCO service coordinator’s documentation must also support that the member meets the eligibility criteria for respite care. The MCO service coordinator should provide supporting documentation regarding the number of hours requested or authorized when the 30-day maximum is requested or authorized. Respite care cannot be authorized retroactively. For STAR+PLUS HCBS program members who have an emergency need for respite care and respite care is not authorized on the ISP, the provider must contact the MCO for authorization prior to delivery of respite care services.

The member must be given the opportunity to choose from the contracted providers that are appropriate considering the member’s needs and the licensed capabilities of the provider. In-home respite care is provided by licensed providers contracting with the MCO and/or a Home and Community Support Services Agency (HCSSA) that is contracted with the MCO to provide services. Out-of-home respite care services is provided by licensed nursing facilities (NFs), licensed personal care facilities and licensed AFC homes.

The provider who delivers in-home respite care services is responsible for providing the personal assistance services (PAS) authorized on the ISP, with the possible exception of delegated nursing tasks. When a member is receiving in-home respite care and the attendant providing the personal care is not the same attendant to whom the nursing tasks were delegated, the nurse may directly provide the nursing care. It is necessary for the MCO to modify the ISP to include the increased direct nursing based on information provided by the provider. Other services (for example, physical therapy (PT) or minor home modifications (MHMs)) may continue to be delivered at the same time as the in-home respite care service.

Respite care services can be authorized as often as needed for primary caregiver relief or emergency absences of the primary caregiver up to the 30-day maximum per ISP year, within the limit of the member's cost limit. Respite care services must be authorized on Form H1700-1, Individual Service Plan (Pg. 1)(PDF). For example, if two hours of respite care are to be used per week, the ISP authorization is for eight 15-minute units. The calculation is two hours per week times 52 weeks = 104 hours divided by four 15-minute units. The annual limit on respite care services is 30 days, equivalent to 720 hours, which equals 2,880 units (30 days times 24 hours per day; 720 hours = 2,880 15-minute increments), unless approval to exceed the 30-day limit is given by the MCO. The MCO, who has overall responsibility for the coordination of STAR+PLUS HCBS program services, must keep track of the units a member has used. The provider may use Form H2067-MC, Managed Care Programs Communication (PDF), to notify the MCO of the dates and duration of respite care services delivered. The MCO can track the number of respite care days used.

4311 MCO Approval to Exceed the Respite Care Service Cap

Revision 19-13; Effective November 5, 2019

To request approval to exceed the annual individual service plan (ISP) cost limit on respite care services, the provider must send a written request to the managed care organization (MCO) documenting the:

  • need for additional respite care units;
  • number of additional units needed;
  • cost estimate considering the location(s) in which the respite care services will be delivered;
  • overall service plan is within the member's individual service plan (ISP) cost limit; and
  • ISP is adequate and meets the individual's needs in the community.

The provider includes his or her telephone number and address in the written request. The MCO provides written approval or disapproval of the request.

In reviewing requests to exceed the respite care service limit, the MCO must consider the intent of respite care services to relieve the primary caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:

  • members whose primary caregivers become ill, hospitalized or have a family emergency;
  • extenuating circumstances that cause care to be required beyond routine or periodic respite care relief; or
  • a breakdown in member or family support, causing an increased risk of institutionalization because of the physical burden and emotional stress of providing continuous support and care to a dependent person.

4320 In-Home Respite Care Services

Revision 19-13; Effective November 5, 2019

In-home respite care offers services provided by managed care organization (MCO)-contracted providers, on a short-term basis, to members unable to care for themselves because of the absence or need of relief for their unpaid primary caregiver.

In-home respite care is provided in the member's own home, as authorized on the member's Form H1700-1, Individual Service Plan (Pg. 1), when the unpaid primary caregiver needs relief. The provider is responsible for providing the tasks authorized on the member's ISP and Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, during the time the member is receiving in-home respite care.

The provider must document in the member's clinical record:

  • the in-home respite care services provider was given a briefing on the member's status, needs and preferences prior to delivering services; and
  • dates and duration of the services delivered.

In-home respite care services help prevent member or family support breakdown and the consequent institutionalization, which may result from the physical burden and emotional stress of providing continuous support and care to a dependent person.

The in-home respite care services provider must deliver the personal assistance services (PAS). The MCO may allow the in-home respite care services provider's registered nurse (RN) the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home respite care services provider.

In-home respite care services are not intended to be used when the primary caregiver needs to be out of the house for short periods of time (for example, to go to the pharmacy or grocery store to pick up medications or grocery items). The primary caregiver should be encouraged to be out of the house for brief respite care when the attendant is providing the PAS.

4330 Out-of-Home Respite Care Services

Revision 19-13; Effective November 5, 2019

Out-of-home respite care services provide a 24-hour living arrangement in a licensed personal care facility, an adult foster care (AFC) home or a licensed nursing facility (NF) for persons who, because of the unavailability of their primary caregiver, have no one to meet their needs on a short-term basis. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living (ADLs), supervision, and the provision or arrangement of transportation.

Nursing tasks may be directly provided by licensed nurses in out-of-home respite care services or may be delegated as determined by the professional judgment of the provider's registered nurse (RN), unless facility licensure prohibits delegation.

4331 Member Eligibility

Revision 19-13; Effective November 5, 2019

The respite care services member must:

  • meet all eligibility criteria, as specified in section 3200, Eligibility;
  • reside in his or her own home;
  • have a primary caregiver who needs relief either on an emergency or planned short-term basis; and
  • not reside in a personal care facility or adult foster care (AFC).

The applicant for STAR+PLUS Home and Community Based Services (HCBS) program respite care services must complete the same eligibility determination process as other STAR+PLUS HCBS program applicants.

4332 Provider Qualifications

Revision 19-13; Effective November 5, 2019

Out-of-home respite care services providers must be a:

  • licensed personal care facility nursing facility (NF);
  • Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home; or
  • licensed nursing facility (NF).

To deliver STAR+PLUS Home and Community Based Services (HCBS) program out-of-home respite care services, the provider must complete and sign a contract with the managed care organization (MCO). The contract must be signed by both the provider and MCO prior to the provider serving members.

4333 Description of Services

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program member may receive out-of-home respite care services in a licensed personal care facility, a Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home or licensed nursing facility (NF), with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements. The STAR+PLUS HCBS program member may take any adaptive aids he or she is using to the out-of-home respite care setting.

The managed care organization (MCO) provides the out-of-home respite care provider with the assessments and ISP attachments pertinent to the services the member will receive while in the facility or home. The provider must deliver services as identified on the member's ISP attachments.

4334 Respite Care Services in a Personal Care Facility or AFC Home

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a personal care facility or adult foster care (AFC) home may receive nursing services or therapy services from outside providers while residing in the respite care setting. The member's need for any service must be authorized on his or her individual service plan (ISP) before he or she receives the service.

The STAR+PLUS HCBS program member receiving respite care services in an AFC home must qualify for placement in the particular level of AFC home by meeting the specific criteria for that level of home.

Nursing services provided in a Level I or Level II AFC home may be delegated, according to the professional judgment of the provider's registered nurse (RN). Personal care facility licensure prohibits delegation of nursing tasks. In assisted living out-of-home respite care settings, nursing services must be provided directly by licensed nurses.

4335 Respite Care Services in a Nursing Facility

Revision 19-13; Effective November 5, 2019

The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a nursing facility (NF) may receive therapy services from outside providers. The member's need for any service must be authorized on the individual service plan (ISP) before receiving the service. The NF is responsible for providing the needed nursing services to the member.

4340 Room and Board Charges

Revision 19-13; Effective November 5, 2019

Room and board (R&B) charges are not allowable charges to the STAR+PLUS Home and Community Based Services (HCBS) program member receiving out-of-home respite care services. R&B charges are included in the rates for the respite care services.

4400, Emergency Response Services

4410 ERS Introduction

Revision 19-13; Effective November 5, 2019

Emergency Response Services (ERS) are provided through an electronic monitoring system and are used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-days-a-week monitoring capability, helps to ensure the appropriate person or service provider responds to an alarm call from a member.

4420 ERS Program Purpose

Revision 19-13; Effective November 5, 2019

The purpose of Emergency Response Services (ERS) under the STAR+PLUS Home and Community Based Services (HCBS) program is to:

  • enable aged and disabled persons to maintain dignity, independence, individuality, privacy, choice and decision-making ability; and
  • prevent or reduce inappropriate institutional care by providing home-based care and other forms of less intensive care.

4430 ERS Member Eligibility

Revision 23-2; Effective May 15, 2023

A member must meet the following criteria to be eligible for Emergency Response Services (ERS) through the STAR+PLUS Home and Community Based Services (HCBS) program:

  • have been determined eligible for the STAR+PLUS HCBS program;
  • be mentally alert enough to operate the equipment properly, in the judgment of the managed care organization (MCO) service coordinator;
  • have a phone with a private line if the system requires a private line to function properly;
  • be willing to sign a release statement that allows the responder to make a forced entry into the member's home if he or she is asked to respond to an activated alarm call and has no other means of entering the home to respond; and
  • live in a place other than an adult foster care (AFC), assisted living facility (ALF), institution or any other setting where 24-hour supervision is available.

4440 ERS Referral and Selection of Providers

Revision 19-13; Effective November 5, 2019

If the member is considered eligible for Emergency Response Services (ERS), the managed care organization (MCO) shares a contracted list of all ERS providers with the member, who selects a provider from the list. The member can request a provider change; however, the member must contact his or her MCO service coordinator to request the change.

The MCO follows the procedures in Section 3600, Ongoing Service Coordination, and gives the member an explanation of the service and requirements.

4450 ERS Duties

Revision 19-13; Effective November 5, 2019

If the member wants and appears to be in need of Emergency Response Services (ERS), the managed care organization (MCO) service coordinator determines if the member meets the general criteria for participating in ERS, as described in Section 4430, ERS Member Eligibility. The MCO may involve other members of the interdisciplinary team (IDT) in the decision regarding the member's physical and mental ability to participate in the ERS program. ERS may be authorized through the STAR+PLUS Home and Community Based Services (HCBS) program when it appears the member may need the capability to notify a respondent of an emergency. ERS services are limited to members who:

  • live alone;
  • are alone for significant parts of the day;
  • have no regular primary caregiver for extended periods of time and who would otherwise require extensive supervision; or
  • live with someone who is too incapacitated to call for help should the need arise.

During the course of the services, the MCO and the provider have the joint responsibility of keeping each other informed of changes or problems.

4460 Provider Duties

Revision 19-13; Effective November 5, 2019

Managed care organization (MCO) contracted providers' duties specific to Emergency Response Services (ERS) are described in Title 40 Texas Administrative Code (TAC) Part 1, Chapter 52, Subchapter D.

4500, Home-Delivered Meals

4510 Home-Delivered Meals Description

Revision 19-13; Effective November 5, 2019

The home-delivered meals (HDMs) benefit provides hot, nutritious meals that are served in the member's home. Meals provided by contracted agencies are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a baccalaureate degree with major studies in food and nutrition, dietetics or food service management.

4520 Provider Responsibilities

Revision 19-13; Effective November 5, 2019

Home-delivered meals (HDMs) are delivered to the member’s home as authorized by the managed care organization (MCO). The individual delivering the meal reports any member illnesses, potential threats to his or her safety, or observable changes in the member’s condition to the provider. The provider must notify the MCO service coordinator about the report within 24 hours.

The provider also informs the MCO service coordinator whenever:

  • the HDM is found uneaten or untouched and the member cannot be found; or
  • the meals are repeatedly found to be uneaten or untouched.

This report must also reach the MCO within 24 hours of the event.

The MCO must notify the provider on the day that meals services are suspended. The MCO must suspend services in any of the following situations:

  • Member enters an institution.
  • Member requests that services be suspended or terminated.
  • Member dies.
  • MCO service coordinator directs the provider to suspend services.

Unless the interruption is the result of one of the above situations, the provider must obtain the MCO service coordinator's approval for service interruptions of more than two consecutive days. When the member requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the MCO service coordinator.

4520.1 Frozen or Shelf-Stable Meals

Revision 19-13; Effective November 5, 2019

A provider that contracts with the managed care organization (MCO) to provide home-delivered meals (HDMs) must agree to provide services:

  • for a specific number of service days, with a minimum of five meals per week; and
  • to all eligible members in the service area unless services are suspended or the provider is unable to provide a certain therapeutic medical diet.

Providers of HDMs must submit a waiver request to the MCO if the provider determines that delivery of frozen or shelf-stable meals is required for certain individuals within the provider’s contracted service area. Any waiver granted is effective for a period not to exceed one fiscal year. The provider must not implement the waiver for delivery of a hot meal five days a week before MCO approval of the waiver request.

4600, Transition Assistance Services

4610 Transition Assistance Services Introduction

Revision 19-13; Effective November 5, 2019

Transition Assistance Services (TAS) is a STAR+PLUS Home and Community Based Services (HCBS) program service designed to assist Medicaid members who are transitioning from a nursing facility (NF) to the community. An NF resident discharged from the NF into a waiver program is eligible to receive up to $2,500 in TAS for assistance with setting up a household. TAS is available on a one-time only basis and is not available to residents moving from an NF who are approved for any of the following waiver services:

  • adult foster care (AFC) services; or
  • assisted living facility (ALF) services.

4611 Transition Assistance Services Service Description

Revision 19-13; Effective November 5, 2019

Transition Assistance Services (TAS) pays for non-recurring, set-up expenses for members transitioning from nursing facilities (NFs) to a home in the community. TAS is a benefit to cover basic and essential household items. Allowable expenses are those necessary to enable the member to establish a basic household and may include:

  • payment of security deposits required to lease an apartment or home;
  • set-up fees or deposits to establish utility services for the home, including telephone, electricity, gas and water;
  • purchase of essential furnishings for the apartment or home, including table, chairs, window blinds, eating utensils, food preparation items, bath linens, cleaning supplies and toiletries;
  • payment of moving expenses required to move into or occupy the home or apartment; and
  • payment for services to ensure the health and safety of the member in the apartment or home, such as pest eradication, allergen control or a one-time cleaning before occupancy.

TAS does not include relocation services and is not available to assist the applicant in locating a residence.

4620 Transition Assistance Services Procedures at the Initial Interview

Revision 19-13; Effective November 5, 2019

All STAR+PLUS Home and Community Based Services (HCBS) program applicants who are in a nursing facility (NF) must be advised of the availability of Transition Assistance Services (TAS) and screened for the potential need for services.

Within 14 business days of learning of a request to move to the community, the managed care organization (MCO) service coordinator discusses the applicant’s or member’s available living arrangements in the community and asks the applicant or member where he or she intends to live upon discharge from the NF.

TAS may be considered when the applicant or member:

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

If these or any other situations exist in which the applicant could benefit from TAS services, continue with the screening for TAS.

4630 Identification of Needed Items and Services

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) conducts the interview with the applicant and/or authorized representative (AR) to identify the applicant's needs and determines if other resources are available to meet the needs. The MCO service coordinator completes Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, by marking each identified need and writing a description of the exact need.

Example: If the applicant needs a deposit made for electricity, the MCO enters the name and address of the utility company and the amount required.

The applicant selects a TAS agency from the list of contracted agencies.

4640 Items and Services Included Under TAS

Revision 19-13; Effective November 5, 2019

Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, is divided into three main categories: deposits, household needs and site preparation needs.

4640.1 Deposits

Revision 19-13; Effective November 5, 2019

Deposits include security deposits for rental and utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant’s or member’s name. 
Security deposits may be paid as long as the payment is specifically called a security deposit and not rent, the payment is for a one-time expense, and the amount of the payment is no more than the equivalent of two months’ rent. Transition Assistance Services (TAS) cannot pay for rent.

TAS can be used to pay for arrears on previous utilities if the account is in the member's name and the member will not be able to get the utilities unless the previous balance is paid. TAS cannot pay the first month's payment on utilities.

TAS can be used to pay for a telephone since it is a basic need, but minutes or services on the telephone are not allowable expenses.

TAS cannot pay for any charges for upgraded services beyond the basic service.

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 has a policy that requires a minimal supply of fuel to be delivered during the initial or reconnection service call. TAS funds cannot be used to top off a tank with fuel when the member’s home is connected and has a supply of butane or propane.

4640.2 Household Needs

Revision 19-13; Effective November 5, 2019

Household needs include basic furniture or appliances. This includes bedroom furniture, living room furniture, kitchen furniture, refrigerator, stove, washer, dryer, cleaning supplies and toiletries, etc.

An applicant or member may request a specific brand or type of appliance, furniture or other Transition Assistance Services (TAS) item if the applicant’s or member’s needs are met within the cost limit.

TAS items may be placed in a home other than the applicant’s or member’s only when furnishings are not available and are necessary for the applicant or member to transition to the community. TAS cannot pay for items that would only be used by the other person.

If existing items are not usable and the lack of a usable basic or essential item creates a barrier keeping the member from returning to the community, the item is considered a need.

4640.3 Housewares

Revision 19-13; Effective November 5, 2019

Housewares can include pots, pans, dishes, silverware, cooking utensils, linens, towels, clock and other small items required for the household.

4640.4 Small Appliances

Revision 19-13; Effective November 5, 2019

Small appliances include a microwave oven, electric can opener, coffee pot, toaster, etc.

4640.5 Cleaning Supplies

Revision 19-13; Effective November 5, 2019

Cleaning supplies include a mop, broom, vacuum, brushes, soaps and cleaning agents.

4640.6 Other Items Not Listed

Revision 19-13; Effective November 5, 2019

Any special requests from the applicant or member not covered in the general list that meet the criteria as basic essential items to move to the community may be considered.

4641 Services and Items Not Included in TAS

Revision 19-13; Effective November 5, 2019

Transition Assistance Services (TAS) does not include any items or services that are included under STAR+PLUS Home and Community Based Services (HCBS) program services such as adaptive aids, minor home modifications (MHMs), medical supplies or medications.

TAS does not include any recreational items or appliances, including televisions, VCR or DVD players, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not cover the cost of repairs or expansion on the member’s dwelling. TAS is not used for remodeling or renovation, upgrading of existing items or purchasing non-essential items.

TAS funds cannot be used for food. The managed care organization (MCO) may refer the member to emergency Supplemental Nutrition Assistance Program (SNAP) or local food pantry resources.

The room and board (R&B) charge is not an allowable TAS expense.

TAS does not pay for monthly rental or mortgage agreements or ongoing utility charges.

4642 Site Preparation

Revision 19-13; Effective November 5, 2019

Site preparation can include the following services:

  • moving expenses, which include the cost of moving the applicant’s or member’s items from another location, or delivery charges on large purchased items;
  • pest eradication, if the applicant’s or member’s place of residence has been unattended and some type of extermination is needed;
  • allergen control, if the applicant’s or member’s place of residence has been unattended or the applicant or member is moving into a place that poses a respiratory health problem; or
  • one-time cleaning, if the applicant’s or member’s place of 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).

Transition Assistance Services (TAS) cannot pay for septic systems.

4650 Estimated Cost of Items and Services

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) service coordinator provides a description and estimated cost of each item identified as needed under each service category on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The actual cost of an item may be used, if known. The amounts, either actual or estimated, must be less than or equal to $2,500.

The MCO service coordinator must be as specific as possible when describing what items are needed and the estimated cost. The description must include size, color, specific types or any other identifying information, as specified by the member, which will assist the TAS agency in meeting the member’s needs.

4651 Totaling the Estimated Cost and Authorization of TAS

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) service coordinator totals each section of Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and enters the amounts in the totals section to arrive at the final amount to be authorized under the TAS program. The $2,500 total amount is not entered as a flat rate.

The applicant or member must sign the form stating that the items listed are the basic, essential needs required to move into the community, and he or she agrees that the TAS agency selected is authorized to make the purchases for him or her.

The applicant or member selects a TAS agency from the list of contracted agencies.

The MCO service coordinator must explain to the applicant that the service will not be authorized until the applicant is determined eligible for STAR+PLUS Home and Community Based Services (HCBS) program services and notified in writing that he or she is eligible. The MCO service coordinator must contact the applicant or authorized representative (AR) before certification to verify the applicant has made arrangements for relocating to the community and has finalized a projected discharge date.

The MCO service coordinator includes TAS on Form H1700-1, Individual Service Plan (Pg. 1). The MCO service coordinator sends the applicant the notification of eligibility and sends the TAS agency Form 8604 and the authorization. The completion date on the authorization is two business days before the projected nursing facility (NF) discharge date. Allow at least five business days between the authorization date and the completion date. The TAS agency is expected to have all services and items completed by that date. For situations in which a shorter completion date is needed, the MCO service coordinator must contact the TAS agency and negotiate an earlier date. The MCO service coordinator will code those items as delivered prior to the arrival date.

Additional applicant information to the TAS agency may be included on Form 8604 or Form H2067-MC, Managed Care Programs Communication. Form 8604 is mailed after the applicant or member is determined eligible for STAR+PLUS HCBS program services.

The TAS agency may only obtain items or services for which the agency has received authorization on Form 8604. If the TAS agency identifies other items or services that the applicant or member may need, the TAS agency must obtain prior approval from the MCO. Refer to Section 4652, Changes to the Authorization, below.

4652 Changes to the Authorization

Revision 19-13; Effective November 5, 2019

If the Transition Assistance Services (TAS) agency or the member identifies additional items required by the member after the TAS authorization has been sent, the TAS agency must obtain approval from the managed care organization (MCO) on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, prior to obtaining the item or service.

The TAS agency must stay within the total dollar amount authorized on Form 8604. If the total amount of the items or services needed is more than the total amount authorized, the TAS agency must obtain prior approval and an updated Form 8604 from the MCO. The MCO service coordinator must update Form H1700-1, Individual Service Plan (Pg. 1), to reflect the change in the amount for funds authorized.

The MCO must send an amended Form 8604 updating the authorization to the TAS agency within two business days with the additional items and amounts authorized.

MCO approval is required to authorize delivery of TAS services.

4660 Transition Assistance Services Agency Responsibilities

Revision 19-13; Effective November 5, 2019

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 forms carefully and contact the MCO if there are any questions regarding what has been authorized. 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, if necessary, to discuss the item in question. The MCO provides a revised TAS authorization form 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 or services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the dollar amount authorized by the MCO. The TAS agency contacts the member 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 or AR by the completion date to confirm that all authorized TAS services were delivered.

4670 Three-Day Monitor Required

Revision 19-13; Effective November 5, 2019

The managed care organization (MCO) monitors the member within three business days after the discharge date to assure that all services and items authorized through the Transition Assistance Services (TAS) agency have been received. If the member reports that 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 member’s case record.

4680 Failure to Leave the Nursing Facility

Revision 19-13; Effective November 5, 2019

While the managed care organization (MCO) makes every effort to confirm that the member has definite plans to leave the nursing facility (NF), there may be situations in which the member changes his or her mind or has a change in his or her health making it impossible for the member 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 member 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 member.

  • 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 member 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 members whose needs are similar to those of the member for whom the items were purchased or must be dedicated to assisting the member 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 costs 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.

5100, TxMedCentral

5110 File Maintenance

Revision 18-0; Effective September 4, 2018

Due to the volume of forms being uploaded to TxMedCentral, it is mandatory to purge older documents from time to time. Program Support Unit (PSU) staff must electronically back up documents from the managed care organization’s (MCO’s) ISP and SPW folder on a daily basis to prevent loss of form history. Documents must be easily accessible to PSU staff whenever needed. Texas Health and Human Services Commission (HHSC) requires these backup documents be maintained for five years.

5120 Maintenance Requirements for Member Information and Forms

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must establish and maintain a case record for each STAR+PLUS Home and Community Based Services (HCBS) program member. PSU staff must not update documents directly in TxMedCentral. Instead, PSU staff must move files daily to a secure location. Documents must be easily accessible to PSU staff whenever needed.

5130 Managed Care Data in the Texas Integrated Eligibility Redesign System

Revision 18-0; Effective September 4, 2018

5130.1 County Code Issues Affecting Enrollment

Revision 18-0; Effective September 4, 2018

The Service Authorization System Online (SASO) reflects the residence county as recorded in the Texas Integrated Eligibility Redesign System (TIERS). Correction to the county code must be done in TIERS. Program Support Unit (PSU) staff must inform the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by faxing Form H1746-A, MEPD Referral Cover Sheet, to correct the county code. Incorrect county code records in TIERS can cause enrollment problems for applicants or members in STAR+PLUS.

Supplemental Security Income Cases

If an individual receives Supplemental Security Income (SSI), TIERS derives the county based on the residential Zoning Improvement Plan (ZIP) code provided by the Social Security Administration (SSA). If the ZIP code is incorrect, it can be because of one of two common problems:

  • an incorrect ZIP code; or
  • a ZIP code crosses county lines.

Either of these issues can cause TIERS to assign the wrong county.

Non-SSI Cases

If the individual has any SSI type program (TP) other than TP 12 or TP 13, TIERS contains the county code entered by the MEPD specialist. When not having TP 12 or TP 13, common problems are when:

  • an individual moves without notifying the MEPD specialist; or
  • an MEPD specialist enters an incorrect county code.

What to Do to Resolve Address Issues Affecting Enrollment

  1. Perform an inquiry in TIERS and determine the TP.
  2. If the TP is anything but 12 or 13 and the residence county is incorrect, refer the matter to the MEPD specialist to correct the residence county field.
  3. If the TP is 12 or 13:
  • Determine the residence ZIP code recorded in TIERS.
  • If the residence ZIP code is not correct, the individual must report the correct ZIP code to SSA.
  1. If the residence ZIP code in TIERS is correct but the county is incorrect, PSU staff email the Data Integrity Unit (DIU) at the CCC_Data _Intergrity_Program mailbox the following information:
  • individual's name as recorded in TIERS;
  • individual's Medicaid identification (ID) number;
  • residence ZIP code; and
  • residence county as it should be reflected in TIERS.

The DIU can update TIERS to correct the problem. The correction will take place during the next TIERS cutoff processing, usually around the 20th day of the month. SASO should reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff.

5130.2 Service Interruptions Resulting from County Code Mismatches in TIERS

Revision 18-0; Effective September 4, 2018

Because participation in managed care programs is based on an individual's residence county, as recorded in the Texas Integrated Eligibility Redesign System (TIERS), service interruptions can occur when the TIERS record shows the wrong residence county code.
The Service Authorization System Online (SASO) reflects the residence county as recorded in TIERS and is updated through a monthly interface. Therefore, incorrect county code data in SASO must be corrected in TIERS. The manner in which this correction occurs depends on the individual's type program (TP). If a residential county code is incorrect and the individual receives services under:

  • TP 12 or 13 in TIERS, the individual or his or her authorized representative (AR) must contact the Social Security Administration (SSA) to request a correction. The Data Integrity Unit (DIU) can correct problems in TIERS that result from Zoning Improvement Plan (ZIP) codes that cross county lines. In these situations, SSA assigns a default county code in the computer program matrix, which is transferred to TIERS data files. Results of correction requests to the DIU di_managedcare mailbox, take place during the next TIERS cutoff, usually around the 20th day of the month. SASO will reflect the corrected county during the first TIERS-to-SASO reconciliation that occurs after TIERS cutoff, usually the day after cutoff. Describe the needed change in the email and send the following information:
    • individual's name as recorded in TIERS;
    • individual’s Medicaid identification (ID) number; and
    • correct ZIP code and residence county as it should be reflected in TIERS.
  • TP 03, TP 18, TP 19, TP 21, TP 50, TP 87 or TP 88 in TIERS, 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 assigned to the HEART case record and request a correction.
  • Supplemental Nutrition Assistance Program (SNAP), PSU staff must fax Form H1746-A to the MEPD specialist assigned to the HEART case record and request a correction.

5131 Identifying Managed Care Members in TIERS

Revision 24-1; Effective Feb. 22, 2024

Program Support Unit (PSU) staff must verify if an individual, applicant or member is enrolled in managed care by checking the Texas Integrated Eligibility Redesign System (TIERS). TIERS contains a managed care segment for all individuals, applicants or members who are currently or have been enrolled in managed care.

PSU staff must complete the following activities in TIERS:

  • Enter the individual's, applicant’s or member’s information in the Individual-Search screen and select Search. The results of the search will appear in the Search Results field.
  • Select the hyperlink of the individual’s name in the Search Results field. The Individual-Summary screen will appear.
  • Hover over the Individual # field and select Managed Care from the dropdown menu. The managed care information will appear in the Individual Managed Care History field. The data elements in the Individual Managed Care History field include:
    • Provider — The name of the provider contracted by the MCO to deliver services to members.
    • Plan — The name and plan code of the MCO providing Medicaid services to the member.
    • Program — For managed care members, "STARPLUS" will appear in this field.
    • County — Individual's county of residence.
    • Begin Date — The date enrollment began under this plan.
    • End Date — The date enrollment ended under this plan.
    • Status — Describes the type of action.
    • Eligibility — Choices are "candidate" (applicant), "enrolled" (active) and "suspended" (closed).
    • Candidature — Describes the individual's status.

5200, Service Authorization System Online (SASO)

5210 Managed Care Data in SASO

Revision 18-0; Effective September 4, 2018 
  
The STAR+PLUS Home and Community Based Services (HCBS) program is authorized by the managed care organization (MCO) and registered by Program Support Unit (PSU) staff in the Service Authorization System Online (SASO) with a Service Group (SG) 19 and Service Code (SC) 12 or 13. If the member's individual service plan (ISP) is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal registers the appropriate SG/SC combination, which is verified by PSU staff. Service codes are based on the following:

  • Service Code 12: Use this service code when registering initial service authorizations or annual re-determination service authorizations received up to 90 days prior to the end date of the current ISP.
  • Service Code 13: Use this service code if an ISP is received after the end date of the most recent ISP. Register one service authorization using Service Code 13 effective the day after the end date of the most recent ISP and with an end date that is the end of the month in which the new ISP was received. Register a second service authorization using Service Code 12 with an effective date one day after the Service Code 13 service authorization ends and an end date of one year minus a day from the effective date of the ISP.

Example: A reassessment ISP is received on June 5, 2019, for an ISP that ended May 31, 2019. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2019, and an end date of June 30, 2019. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2019, and an end date of May 31, 2020.

Example of automatic registration: A reassessment ISP is submitted to the TMHP LTC Online Portal on June 5, 2019, for an ISP that ended May 31, 2019. One service authorization record with "Service Code 13 — Nursing" will be system-generated with a begin date of June 1, 2019, and an end date of June 30, 2019. A second service authorization record with "Service Code 12 — Case Management" will be system-generated with a begin date of July 1, 2019, and an end date of May 31, 2020.

5220 Closing Institutional Service Records in SASO

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff must contact Provider Claims Services (PCS) at the established hotline to assist in closing a Service Authorization System Online (SASO) Category 1 nursing facility (NF) authorization for individuals being discharged from an NF and will begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program. The Texas Health and Human Services Commission (HHSC) Long Term Care (LTC) PCS hotline is 512-438-2200. Select Option 1 when prompted to do so.

PSU staff should call the hotline directly to request the NF record in SASO be closed so non-institutional services can be authorized. PSU staff must confirm the member has been discharged from the NF and community services are negotiated to begin on or after the date of discharge.

When calling the HHSC LTC PCS hotline, PSU staff must identify themselves as HHSC employees and report the member has been discharged from the NF, providing the discharge date. The PCS representative will close all Group 1 service authorizations and enrollment records in SASO, including the Service Code 60 record. This procedure applies whether or not the individual is leaving the NF using the Money Follows the Person (MFP) option.

5230 MFPD Entitlement Tracking and SASO Data Entry

Revision Notice 23-3; Effective Aug. 21, 2023

Time spent in a nursing facility (NF) does not count toward the Money Follows the Person Demonstration (MFPD) 365-day period. Therefore, the MCO will track to ensure MFPD members receive the full 365-day entitlement period. The entitlement period begins the date the member is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) uploads Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, indicating the total number of days the member spent in the NF. The MCO must send this information to Program Support Unit (PSU) staff after the 365th day. PSU staff may refer to the table below for help making  accurate entries in the Service Authorization System Online (SASO).

Example 1 — No institutionalization during the 365-day period

Begin DateEnd DateService GroupService CodeCase ProgressionFund Code
02-13-1906-15-1911The applicant discharged from the NF. The NF begin and end dates are derived from forms submitted by the NF.Blank
06-01-1906-01-191912PSU staff enter the one-day registration record in SASO for MCO capitation payment for applicants who are not enrolled with an MCO at the beginning of the MFP process. Blank
06-15-1906-14-201912PSU staff enter SASO record's fund code as 19MFP for the entire period.19MFP
06-15-2006-30-201912PSU staff enter the remaining individual service plan (ISP) period without the 19MFP fund code.Blank

Example 2 — Institutionalization during the 365-day period

Begin DateEnd DateService GroupService CodeCase ProgressionFund Code
02-13-1706-15-1811The applicant discharged from the NF. The NF begin and end dates are derived from forms submitted by the NF.Blank
06-01-1806-01-181912PSU staff enter the one-day registration record in SASO for the MCO capitation payment for applicants who are not enrolled with an MCO at the beginning of the MFP process. Blank
06-15-1806-14-191912PSU staff enter SASO record’s fund code as 19MFP for the entire period.19MFP
06-15-1906-30-191912PSU staff enter the remaining ISP period without the 19MFP fund code.Blank
The MCO has notified PSU staff that this member spent 15 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:
06-15-1906-29-191912PSU staff enter the MFPD period for the 15 days the individual was in the hospital.19MFP
06-30-1906-30-191912MFPD period reached the 365th day on 06-29-19. The ISP has one day remaining.Blank

Example 3 — Institutionalization during the 365-day period

Begin DateEnd DateService GroupService CodeCase ProgressionFund Code
02-13-1906-15-2011The applicant has discharged from the NF. The NF begin and end dates are derived from forms submitted by the NF.Blank
06-01-2006-01-201912PSU staff enter the one-day registration record in SASO for the MCO capitation payment for applicants who are not enrolled with an MCO at the beginning of the MFP process. Blank
06-15-2006-14-211912PSU staff enter the SASO record’s fund code as 19MFP for the entire period.19MFP
06-15-2106-30-211912PSU staff enter the remaining ISP period without the 19MFP fund code.Blank
07-01-2106-30-221912PSU staff update the reassessment ISP dates, if applicable.Blank
The MCO has notified PSU staff that the member spent 25 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:
06-15-2106-30-211912PSU staff enter the MFPD period for 16 of the 25 days the individual was in the hospital.19MFP
07-01-2107-09-211912PSU staff enter the MFPD period for the last 9 of the 25-day period in which the individual was in the hospital.19MFP
07-10-2106-30-221912PSU staff enter the remainder of the reassessment ISP period.Blank

5300, Texas Medicaid and Healthcare Partnership Long Term Care Online Portal

5310 Using the TMHP Long Term Care Online Portal

Revision 24-1; Effective Feb. 22, 2024

The managed care organization (MCO) must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) to process a determination of MN and the Resource Utilization Group (RUG) value. MCOs submit the MN/LOC Assessment as an:

  • initial MN/LOC Assessment for an applicant or individual being assessed for the STAR+PLUS Home and Community Based Services (HCBS) program;
  • annual MN/LOC Assessment for a member's ongoing eligibility for the STAR+PLUS HCBS program; 
  • a significant change in status MN/LOC Assessment for a STAR+PLUS HCBS program member requesting a change to their RUG.

The MCO must generate an amended individual service plan (ISP) when a significant change occurs in a member’s condition. The MCO must keep amended ISPs in the MCO’s member case file. The MCO does not provide the amended ISP to Program Support Unit (PSU) staff and does not enter the amended ISP in the TMHP LTCOP. PSU staff must advise the MCO that PSU staff do not process ISPs resulting from a significant change if the MCO uploads an amended ISP to the MCOHub.

The MCO has access to the TMHP LTCOP to:

  • check and verify MN status and RUG;
  • review workflow actions that result from the submittal of the MN/LOC Assessment or the individual service plan (ISP);
  • manage and act in response to workflow messages; and
  • submit Form H1700-1, Individual Service Plan, for initial, change, and reassessment of members except for age-outs and nursing facility (NF) residents transitioning to the STAR+PLUS HCBS program.

Submittal of the MN/LOC Assessment through the TMHP LTCOP creates MN, Level of Service (LOS) and Diagnosis (DIA) records in the Service Authorization System Online (SASO). The RUG value is in the LOS record.

Status messages appear in the TMHP LTCOP workflow folder when an MN/LOC Assessment is submitted. Error messages with status codes appear when TMHP processing cannot be completed. Status messages may generate when:

  • assessments have missing information;
  • the system cannot match the assessment to an applicant or individual record;
  • the individual is enrolled in another Medicaid waiver program;
  • assessment forms are out of sequence;
  • corrections are made to assessments after submission to SASO records have already been generated based on the assessment;
  • changes occur in MN or LOS status that affect the member’s services; or
  • PSU staff manually changed historic SASO records within the current ISP period.

This list is not all-inclusive.

PSU staff must:

  • document responses in the TMHP LTCOP to workflow messages appearing for an individual by clicking on applicable buttons related to the messages; and
  • check TMHP LTCOP workflow items to process case actions.
     

5400, Administrative Payment Process

Revision 18-0; Effective September 4, 2018

When an individual is aging out of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP), Medically Dependent Children Program (MDCP) or has been approved for a nursing facility diversion (NFD) slot, the managed care organization (MCO) must authorize services to start on the day of eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program, which may not be the first of the month. If the eligibility date is not the first of the month, the MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date, as applicable. The administrative payment process must be used for the Texas Health and Human Services Commission (HHSC) to issue payment to the MCO and for the MCO to pay the provider.

Once the MCO authorizes services, the provider:

  • prepares Form 1500, Health Insurance Claim; and
  • submits Form 1500 to the MCO within the 95-day filing deadline.

Within five business days of receiving Form 1500, the MCO verifies the provider was authorized to deliver the services billed on Form 1500. The information on Form 1500 meets the clean claim requirements, as defined in the Uniform Managed Care Manual (UMCM), §2.0, and the claim met the 95-day filing deadline. Once the MCO verifies this information, the MCO:

  • sends Form 1500 by secure email to Program Support Unit (PSU) staff if the provider:
    • is authorized to deliver the service;
    • met the clean claim requirements; and
    • submitted the claim to the MCO within the 95-day filing deadline; or  
  • denies payment via the MCO denial process if the provider:
    • is not authorized to deliver the services;
    • did not meet the clean claim requirements; or
    • did not meet the 95-day filing deadline.

Within two business days of receiving Form 1500, PSU staff must:

  • verify the member is Medicaid eligible and has a valid Medical Necessity and Level of Care (MN/LOC) Assessment and individual service plan (ISP);
  • print the Service Authorization screen from Service Authorization Services Online (SASO) and the Medicaid eligibility and Managed Care enrollment screens in the Texas Integrated Eligibility Redesign System (TIERS);
  • prepare Form 4116, Authorization for Expenditures;
  • create a Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record that includes the:
    • Services Authorization screen print from SASO;
    • Medicaid Eligibility screen print from TIERS;
    • Managed Care Enrollment screen print from TIERS;
    • Form 1500; and
    • Form 4116.
  • email Form 4116, Form 1500 and the screen prints to the Enrollment Resolution Services (ERS) mailbox.

Within two business days from the receipt of the email from PSU staff, the assigned ERS staff will:

  • verify the member is Medicaid eligible; and
  • review the claim to determine if it will be paid or denied.

If the decision is to approve to pay the administrative payment, the ERS staff will:

  • email the approved Form 4116 to the Contract Compliance and Support (CCS) Unit mailbox for processing; and
  • notify by email the PSU staff who emailed the request that the administrative payment has been approved.

If the decision is to approve the administrative payment, the following also occurs:

  • The CCS Unit sends the approved payment voucher to the State Comptroller for processing and payment to the MCO; and
  • the MCO pays the provider within one week of receipt of payment from the State Comptroller.

If the decision is to deny the administrative payment, the ERS staff will notify the PSU staff via email, who submitted the request for administrative payment. This email response will also include the reason for denial.

Within two business days of receipt of email from ERS staff, PSU staff will:

  • notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions;
  • upload the email from ERS and the MCO notification to the HEART case record; and
  • close the HEART case record.

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 STAR+PLUS Home and Community Based Services (HCBS) program; 
  • 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 mail Form 2442, Notification of Interest List Release Closure, as notification of STAR+PLUS HCBS program interest list closure to an individual when the individual does not meet STAR+PLUS HCBS program eligibility. PSU staff must always mail Form 2442 with Appendix XII, STAR+PLUS HCBS Program Description. Form 2442 does not provide the right to request a state fair hearing. Individuals only receive Form 2442 and will never receive Form H2065-D, Notification of Managed Care Program Services.

PSU staff mail an applicant or member Form H2065-D when denied or terminated from the STAR+PLUS HCBS program. Form H2065-D provides the applicant or member with the right to request a state fair hearing. Applicants and members 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 the adverse action notification period 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 §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:

  1. The agency has factual information confirming the death of an individual, applicant or member;
  2. The agency receives a clear written statement signed by a member that:
    1. They no longer want to receive services; or
    2. 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;
  3. The  individual, applicant or member has been admitted to an institution where he or she is ineligible under the plan for further services;
  4. 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);
  5. 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;
  6. A change in the level of medical care is prescribed by the applicant’s or member’s physician; or
  7. The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act;
  8. 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 STAR+PLUS HCBS 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) §353.1153(a)(1) in order to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program:

  • be 21 years of age or older;
  • 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 of the STAR+PLUS HCBS program services;
  • choose the STAR+PLUS HCBS program 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 HCBS waiver program approved by Centers for Medicaid & Medicare Services (CMS); 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 §360 (relating to Medicaid Buy-In Program).

6200, Adverse Action Notification Period

Revision 22-2; Effective March 4, 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 prior to 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 STAR+PLUS Home and Community Based Services (HCBS) program services until a state fair hearing decision is rendered. 

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

The STAR+PLUS HCBS program termination dates are typically on the last day of the month. PSU staff must manually extend the end date all service group (SG) 19 records in the Service Authorization System Online (SASO) to the last day of the following month if:

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

See the example chart below for further clarification.

Example Chart

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

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

  • PSU staff has factual information confirming the death of a member;
  • the member submits a signed written statement waiving their right to the adverse action notification period and understands their services will end;
  • the member is denied Medicaid financial eligibility for the STAR+PLUS HCBS program;
  • the member is admitted to an institution for 90 consecutive days where STAR+PLUS HCBS program 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 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility upon verification an applicant or member is deceased. PSU staff must take similar action upon verification that an individual is deceased.

PSU staff may receive notification of an individual, applicant or member’s date of death by:

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

PSU staff must verify the individual, applicant 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 the MCOHub 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; 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 the MCOHub 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, 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) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • upload applicable documents to the HEART case record; 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 the MCOHub notifying the MCO of the member’s date of death and case closure, if applicable;
  • for MAO members, fax Form H1746-A to the MEPD specialist if TIERS does not show the member is deceased;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload the applicable documents to the HEART case record; 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, applicant or member’s address or family’s address. The applicant 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 July 26, 2021. The member’s termination effective date is July 26, 2021.

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

6300.2 Institutional Stay

Revision 24-2; Effective May 21, 2024

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not live in an allowable living situation. Title 42 CFR Section 441.301(c)(5) states the following settings are not allowed for the STAR+PLUS HCBS program:

  • 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 with 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 with 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 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 (PDF), Managed Care Programs Communication (PDF), to the MCOHub 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) if the MCO is not timely in their notification.

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

  • manually generating Form H2065-D, Notification of Managed Care Program Services (PDF), Notification of Managed Care Program Services (PDF);
  • mailing Form H2065-D to the applicant;
  • uploading Form H2065-D to the MCOHub;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • documenting and closing the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • uploading all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
  • documenting and closing the HEART case record.

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

  • manually generating Form H2065-D;
  • mailing Form H2065-D to the member;
  • uploading Form H2065-D to the MCOHub;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • uploading applicable documents to the HEART case record; and
  • documenting the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO members, email ERS Unit staff the following information:
    • an email subject line that states: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name]”;
    • the member’s name;
    • Medicaid ID number;
    • type of request such as STAR+PLUS HCBS program eligibility termination;
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

A Medicare Part A skilled nursing facility (SNF) provides short-term acute care, and therefore does not count toward the 90-day institutional stay count. The intent of the institutional stay denial reason is for applicants and members that are entering an institution for a long-term stay.

PSU staff must start the 90-day count for a denial or termination when a STAR+PLUS HCBS program applicant or member enters a nursing facility (NF) and Service Authorization System Online (SASO) reflects a continuous stay of the following records:

  • Service Group (SG) 1 – Nursing Facility, Service Code (SC) 1 – Daily Care; or
  • SG 1 – Nursing Facility, SC 3 – ECF.

PSU staff must not count days as part of the 90-day institutional stay count when SASO reflects the following records:  

  • SG 1 – Nursing Facility, SC 3A – SNF Part A Full Medicare; or 
  • SG 8 – Hospice, SC 31 – Nursing Facility Room and Board.

PSU staff must honor the admission date provided by the MCO on Form H2067-MC if NF records do not appear in SASO.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing prior to the termination effective date.

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, procedures outlined in section 3500, Money follows the Person, to reapply for the STAR+PLUS HCBS program and return to the community with services.

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

6300.3 Voluntarily Declined Services

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when notified an applicant or member no longer wants to receive STAR+PLUS HCBS program services. PSU staff must take similar action upon notification that an individual voluntarily declines services.

PSU staff may receive notification of the individual, applicant, member or authorized representative’s (AR’s) request to voluntarily decline the STAR+PLUS HCBS program from:

  • Managed Care Operations;
  • receipt of Form H3675, Application Acknowledgment, indicating no interest in STAR+PLUS HCBS program services;
  • Enrollment Resolution Services (ERS) Unit staff;
  • the individual, applicant, member or AR;
  • 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 XII, STAR+PLUS HCBS Program Description, to the individual;
  • upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of 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; 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;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • document and close the CSIL record, if applicable;
  • invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • upload applicable documents to the HEART case record; 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;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO members, email ERS Unit staff the following information:
    • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

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 AR 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, if the adverse action period is not waived.

6300.4 Financial Eligibility

Revision 22-3; Effective Sept. 27, 2022

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not meet Medicaid financial eligibility. An applicant’s or member’s Medicaid financial eligibility for the STAR+PLUS HCBS program is determined by the:

  • Social Security Administration (SSA) for Supplemental Security Income (SSI); or  
  • Medicaid for the Elderly and People with Disabilities (MEPD) specialist for:
    • medical assistance only (MAO) (type assistance (TA) 10);  
    • Pickle Amendment Group (type program (TP) 03); and
    • Disabled Adult Children (DAC) (TP 18).

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

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

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

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

  • create a Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, if applicable;
  •  verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
  • manually generate Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language;
  • mail the applicant:
    • 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 to TxMedCentral following the instructions in Appendix XXXIV, STAR+PLUS HCBS Program TxMedCentral Naming Conventions;
  • document and close the Community Services Interest List (CSIL) database record, if applicable;
  • upload applicable documents to the HEART case record following the instructions in Appendix XXXIII, STAR+PLUS HCBS Program 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 of termination:

  • verify Medicaid financial eligibility has been terminated by reviewing the TIERS Medicaid/CHIP/CHIP Perinatal History screen;
  • manually generate Form H2065-D following the instructions in Appendix IV;
  • mail the member:
    • Form H2065-D;
    • Form H1200; and
    • Form 2606;
  • upload Form H2065-D on TxMedCentral following the instructions in Appendix XXXIV;
  • manually close all service group (SG) 19 records in Service Authorization System Online (SASO) to align with the date of termination, using the appropriate termination code listed in Appendix IV;
  • upload applicable documents to the HEART case record following the instructions in Appendix XXXIII; and
  • document and close the HEART case record.  

The adverse action notification period does not apply in this situation. The member’s STAR+PLUS HCBS program termination effective date must match the TIERS Medicaid/CHIP/CHIP Perinatal History segment end date even if the TIERS end date is in the past. 

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

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

Refer to 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing prior to the termination effective date.

Notes:

  • The member can resume services if the Medicaid is reestablished with a gap of six months or less. The MCO may use the existing ISP and Medical Necessity and Level of Care (MN/LOC) Assessment if they are still valid. The MCO must conduct a reassessment without penalty if the ISP and MN/LOC have expired.
  • The member must go to the bottom of the interest list to reapply for services if Medicaid is reestablished with a gap greater than six months.

6300.5 Medical Necessity and Level of Care

Revision 23-4; Effective Dec. 7, 2023

Title 26 TAC Section 554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the STAR+PLUS Home and Community Based Services (HCBS) program. 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 STAR+PLUS HCBS program eligibility when an applicant or member’s MN does not meet the level of care (LOC) required for a nursing facility (NF). An applicant or member’s approval and continued eligibility for the STAR+PLUS HCBS program is dependent upon meeting the MN requirements as listed in 26 TAC Section 554.2401. The tool used to determine MN is the Medical Necessity and Level of Care (MN/LOC) Assessment. The managed care organization (MCO) completes the MN/LOC Assessment and uploads it to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The TMHP nurse and physician review the MN/LOC Assessment to determine if the applicant or member meets the MN criteria required for the STAR+PLUS HCBS program.

The MCO conducts:

  • an initial MN/LOC Assessment for each applicant;
  • a reassessment MN/LOC Assessment annually for each member; and
  • a change in condition (CIC) MN/LOC Assessment for each member, when applicable.

The MCO must notify PSU staff of an applicant or member’s MN denial by uploading:

  • Form H3676, Managed Care Pre-Enrollment Assessment Authorization, for applicants; or
  • Form H2067-MC, Managed Care Programs Communication, for members, to the MCOHub.

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 authorized representative (AR) requests a fair hearing.

On the 15th business day from the date the “MN Denied” status initially appears in the 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;
  • mail Form H2065-D and the Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment, to the applicant;
  • for Medicaid Assistance Only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) in the TMHP LTCOP, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; 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;
  • mail Form H2065-D and Appendix XI to the member;
  • terminate the ISP in the TMHP LTCOP using the existing ISP end date as the termination effective date;
  • verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO members, email Enrollment Resolution Services (ERS) Unit staff the following information:
    • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before 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 24-1; Effective Feb. 22, 2024

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when notified an applicant or member cannot be located. PSU staff must take similar action 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+PLUS Handbook (SPH), section 3632.7, Denial/Termination Due to Inability to Locate the Member, 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 XII, STAR+PLUS HCBS Program Description, to the individual;
  • upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of case closure, if applicable;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; and
  • document and close the HEART case record.

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

  • upload Form H2067-MC to the MCOHub notifying the MCO of case closure;
  • invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • document and close the CSIL record, if applicable;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

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

  • manually generate Form H2065-D, Notification of Managed Care Program Services;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • document and close the CSIL record, if applicable;
  • invalidate the ISP in the TMHP LTCOP, if applicable;
  • upload applicable documents to the HEART case record; 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;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to MCOHub;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • manually close the following service group (SG) 19 records in the Service Authorization System Online (SASO), if applicable, and ensuring the closure date aligns with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload applicable documents to the HEART case record; and
  • document the HEART case record.

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 complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO members, email ERS Unit staff the following information:
    • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].”
    • the member’s name;
    • Medicaid ID number;
    • type of request such as STAR+PLUS HCBS program eligibility termination;
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

PSU staff must reinstate the STAR+PLUS HCBS program 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.

6300.7 Exceeding the ISP Cost Limit

Revision 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member’s individual service plan (ISP) exceeds the cost limit. The intent of the STAR+PLUS HCBS program 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 the MCOHub.

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;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • invalidate the individual service plan (ISP) 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; 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;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload all applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO members, email ERS Unit staff the following information:
    • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
    • the member’s name;
    • Medicaid ID number;
    • type of request (e.g., STAR+PLUS HCBS program eligibility termination);
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS 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 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must deny STAR+PLUS Home and Community Based Services (HCBS) program eligibility when the managed care organization (MCO) is cannot get a physician’s signature at an initial assessment. The physician’s signature is required to complete the initial Medical Necessity and Level of Care (MN/LOC) Assessment only. The physician’s signature is not required for the annual MN/LOC Assessment.

The MCO must make at least three more attempts to get the physician’s signature if the MCO does not receive a signed copy of the physician’s signature page within five business days of the first request to the applicant or member’s physician. The MCO must contact the applicant or member for help getting the physician’s signature if the MCO is unsuccessful getting the signature from the physician.

The MCO must notify PSU staff if the MCO is cannot get a physician’s signature within two business days of the 45-day time frame for completing all initial assessment activity expiring. The MCO must notify PSU staff by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to the MCOHub notating that the MCO could not get a physician’s signature and the MCO is requesting the applicant be denied.

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;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • document and close the Community Services Interest List (CSIL) record, if applicable;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
  • invalidate the individual service plan (ISP) 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; 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 23-4; Effective Dec. 7, 2023

Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an applicant or member fails to meet other program requirements not listed in Section 6200.1 through Section 6200.8. The PSU supervisor will notify PSU staff if the denial or termination can be processed. PSU staff must deny or terminate STAR+PLUS Home and Community Based Services (HCBS) program eligibility when an applicant or member does not meet the eligibility requirements as noted in Title 1 Texas Administrative Code (TAC) Section 353.1153.

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 XII, STAR+PLUS HCBS Program Description, to the individual;
  • upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of case closure, if applicable;
  • document and close the Community Services Interest List (CSIL) database record, if applicable;
  • upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record; 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;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • for medical assistance only (MAO) Medicaid applicants, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
  • document and close the CSIL database record, if applicable;
  • invalidate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • upload applicable documents to the HEART case record; 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;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub;
  • for MAO Medicaid members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO Medicaid members, email ERS Unit staff the following information:
    • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request such as STAR+PLUS HCBS program eligibility termination
    • individual service plan (ISP) end date;
    • effective date of termination;
    • Form H2065-D;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in the Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

Refer to section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, if an MAO Medicaid member requests a state fair hearing with continued benefits within the adverse action notification period.

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.

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

  • does not have an unmet need;
  • moved out of the state of Texas;
  • declined assessment; and
  • under 21.

6300.10 Other Reasons

Revision 24-1; Effective Feb. 22, 2024

Program Support Unit (PSU) staff must notify the PSU supervisor if they encounter a scenario where an individual, applicant or member may:

  • need a case closure; or 
  • be denied or terminated for reasons not listed in Section 6200.01 through Section 6200.09.

The PSU supervisor will notify PSU staff if:

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

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

  • manually generate Form 2442, Notification of Interest List Release Closure;
  • mail Form 2442 and Appendix XII, STAR+PLUS HCBS Program Description, to the individual;
  • upload Form H2067-MC, Managed Care Programs Communication, to the MCOHub notifying the MCO of 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; and
  • document and close the HEART case record.

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

  • manually generate Form H2065-D, Notification of Managed Care Program Services;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • complete 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 for medical assistance only (MAO) applicants, when applicable;
  • document and close the CSIL record, if applicable;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

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

  • manually generate Form H2065-D;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub;
  • manually close all service group (SG) 19 records in Service Authorization System Online (SASO) to align with the date of termination;
  • upload applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, complete Form H1746-A and fax to the MEPD specialist along with Form H2065-D;
  • for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
    • an email subject line that reads: “STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name]”;
    • the member’s name;
    • Medicaid ID number;
    • type of request such as STAR+PLUS HCBS program eligibility termination;
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and 
  • document and close the HEART case record.

Refer to section 7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program, if the member requests a fair hearing before the termination effective date.

The applicability of the adverse action notification period is scenario-specific. Refer to section 6200, Adverse Action Notification Period, for more information on determining the termination effective date if the supervisor determines the adverse action notification period is applicable.

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

  • does not have an unmet need;
  • moved out of state; 
  • declined assessment; or 
  • under 21. 

6400, Disenrollment Request Policy

Revision 24-1; Effective Feb. 22, 2024 

A managed care organization (MCO) may request a member be disenrolled from managed care for specific reasons of noncompliance listed in the Texas Health and Human Services Commission (HHSC) Uniform Managed Care Manual (UMCM) Chapter 11.5 (PDF). 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 get new members;
  • steadfast refusal to comply with managed care restrictions such as repeatedly using the emergency room along with refusing to allow the MCO to treat the underlying medical condition; or 
  • a member’s failure to pay room and board (R&B) or copayment charges.

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 by 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 the STAR+PLUS Home and Community Based Services (HCBS) program without HHSC approval. Examples where a member may request to voluntarily withdraw from the STAR+PLUS HCBS program voluntarily 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 the STAR+PLUS HCBS program; or
  • member states they no longer want the STAR+PLUS HCBS program because they do not use any STAR+PLUS HCBS program services.

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 the 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;
  • manually close all service group (SG) 19 records in the Service Authorization System Online (SASO) 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 and fax to the Medicaid for 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 HEART case record;
  • 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.

7200, State Fair Hearing Procedures for STAR+PLUS HCBS Program

7210 Timely or Non-timely State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

Only an applicant, member, guardian or authorized representative (AR) may request a state fair hearing. The applicant, member or AR may request a state fair hearing orally or in writing.

A timely state fair hearing request for a STAR+PLUS Home and Community Based Services (HCBS) program denial is received by Program Support Unit (PSU) staff within 90 days from the date listed on Form H2065-D, Notification of Managed Care Program Services. A non-timely state fair hearing request for a STAR+PLUS HCBS program denial is received by PSU staff later than 90 days from the date listed on Form H2065-D.

PSU staff must create the appeal in the Texas Integrated Eligibility Redesign System (TIERS) for all state fair hearing requests that are received, except for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) financial denials.  PSU staff must notify the Centralized Representative Unit (CRU) by creating an appeal task in the Texas Health and Human Services Commission (HHSC) Benefits Portal if a fair hearing request is received for a MEPD or TW financial denial. PSU staff or the data entry representative (DER) must refer to Appendix XXI, Creating an Appeal in TIERS, and Appendix XXXII, Creating an Appeal Task in the HHSC Benefits Portal, when creating records. 

The hearings officer will determine if there is good cause for a non-timely state fair hearing request. The applicant or member is not eligible for a state fair hearing if the hearings officer determines there is no good cause. 

7211 PSU Staff Procedures for Completing Form 4800-D

Revision Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff may receive an oral or written appeal request related to STAR+PLUS Home and Community Based Services (HCBS) program eligibility denial or termination from an: 

  • applicant; 
  • member; or 
  • authorized representative (AR). 

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 a fair hearing request is received.

PSU staff must complete the following activities within three days of receipt of the state fair hearing request:

  • complete Form 4800-D, Fair Hearing Request Summary, ensuring all persons who should attend the state fair hearing are documented; and
  • email Form 4800-D to the data entry representative (DER) and DER supervisor.

The DER must enter the information on Form 4800-D in TIERS within two days.

Depending on the issue being appealed, PSU staff must enter the following staff on Form 4800-D:

  • For medical necessity/level of care (MN/LOC) denial by Texas Medicaid & Healthcare Partnership (TMHP):
    • TMHP representative as the Agency Representative;
    • TMHP supervisor as the Agency Supervisor;
    • managed care organization (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;
    • no Agency Witness is entered; and
    • MCO representative and MCO supervisor as the Observer 
  • 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 must contact the MCO if there is any doubt as to who should be listed on Form 4800-D.

PSU must complete the following activities when completing Form 4800-D:

  • answer all questions in Section 3, Appellant Details Programs;
  • always answer “No” to the question, “Is there a good cause for non-timely?” in Subsection D, Summary of Agency Action and Citation, since this question only applies to TW programs; and
  • indicate the individual service plan (ISP) begin and end dates, as applicable, in Subsection D.

PSU staff must refer to Form 4800-D instructions for more specific directions for form completion and transmittal.

PSU staff must refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

7212 DER Procedures for Entering State Fair Hearing Request

Revision 24-1; Effective Feb. 22, 2024

The data entry representative (DER) creates a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to document the state fair hearing request when the DER receives Form 4800-D, Fair Hearing Request Summary, from Program Support Unit (PSU) staff. The HEART case record and Community Services Interest List (CSIL) record must remain open until a state fair hearing decision is rendered.

The DER must enter the information in the Texas Integrated Eligibility Redesign System (TIERS) within two business days of receipt of Form 4800-D, following the instructions in Appendix XXI, Creating an Appeal in TIERS. The DER must use the Manage Office Resources (MOR) search function in TIERS when adding PSU staff, managed care organization (MCO), Texas Medicaid & Healthcare Partnership (TMHP), or Texas Health and Human Services Commission (HHSC) representatives as participants. TIERS will assign an appeal identification (ID) number once the DER completes all required fields. The DER must send a copy of the TIERS generated Form H4800, Fair Hearing Request Summary, to PSU staff and upload a copy to the HEART case record.

7213 Generation of the State Fair Hearing Packet

Revision 19-13; Effective November 5, 2019

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 authorized representative (AR), such as Texas Health and Human Services Commission (HHSC), the managed care organization (MCO) or Texas Medicaid & Healthcare Partnership (TMHP). 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 sends to the applicant, member or AR. A full state fair hearing packet includes:

7214 State Fair Hearing Evidence Packet

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must complete the following activities on the same day PSU staff enter the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS):

  • prepare a state fair hearing evidence packet;
  • mail the state fair hearing evidence packet to the applicant, member or authorized representative (AR);
  • upload the state fair hearing evidence packet to the Texas Health and Human Services Commission (HHSC) Benefits Portal following the instructions in Section 7231, Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal; 
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; and
  • document the HEART case record.

PSU staff must not enter state fair hearing requests for Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) Medicaid financial denials. The Centralized Representative Unit (CRU) is responsible for creating all state fair hearings in the HHSC Benefits Portal related to MEPD and TW financial denials. Refer to Section 7221.2, Financial Denial by MEPD or TW, for PSU staff responsibilities for MEPD or TW financial denials.

PSU staff must ensure documentation on Form 4800-D, Fair Hearing Request Summary, clearly states the state fair hearing is for the STAR+PLUS Home and Community Based Services (HCBS) program. 

The STAR+PLUS HCBS state fair hearing evidence packet includes:

  • Form 4801, State Fair Hearing Evidence Packet Cover Page;
  • Form H2065-D, Notification of Managed Care Services;
  • the appropriate handbook section, as notated on Form H2065-D;
  • Appendix XX, STAR+PLUS HCBS Program Eligibility TAC; and
  • for MN/Level of Care (MN/LOC) denials or terminations, Appendix XI, STAR+PLUS HCBS Program Medical Necessity Denial Attachment.

PSU staff must ensure all state fair hearing evidence packets are complete, organized and all pages are numbered to support the agency’s action on appeal. 

Other agencies that may be involved in a state fair hearing, such as the managed care organization (MCO), Centralized Representation Unit (CRU) or Texas Medicaid & Healthcare Partnership (TMHP) will:

  • generate their own state fair hearing evidence packet; 
  • upload their state fair hearing evidence packet to the HHSC Benefits Portal; and
  • mail their state fair hearing evidence packet to the applicant, member or AR.

The hearings officer mails Form H4803 to the applicant, member or AR when the state fair hearing is first requested. The applicant, member or AR may fax or mail evidence to the hearings officer if desired. The applicant, member or AR gets the hearings officer’s contact information from Form H4803, Notice of Fair Hearing. The hearings officer shares any evidence submitted by the applicant, member or AR with HHSC.

7215 Changes to the State Fair Hearing Request Summary

Revision 19-13; Effective November 5, 2019

After the data entry representative (DER) has added information from Form 4800-D, 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 Works (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 MEPD or TW, 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 the STAR+PLUS Home and Community Based Services (HCBS) program. 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 19-13; Effective November 5, 2019

7221 Type of Denials

Revision 19-13; Effective November 5, 2019

An applicant, member, guardian or authorized representative (AR) may appeal a decision orally or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to create the state fair hearing in the Texas Integrated Eligibility Redesign System (TIERS) when an applicant, member or AR 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 TMHP) below;
  • a financial denial by MEPD or TW (Refer to Section 7221.2, Financial Denial by MEPD or TW);  
  • a Supplemental Security Income (SSI) denial by the Social Security Administration (SSA) (Refer to Section 7221.3, SSI Denial by the SSA; or
  • for any other denial reasons (Refer to Section 7221.4, Other Denial Reasons).

7221.1 Medical Necessity Denial by TMHP

Revision 19-13; Effective November 5, 2019

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, 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 menu.

When Form 4800-D 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 STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member name back on the STAR+PLUS HCBS program 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 STAR+PLUS HCBS program 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 7400, 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 MEPD or TW

Revision 19-13; Effective November 5, 2019

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). CRU is required to attend the state fair hearing to represent STAR+PLUS Home and Community Based Services (HCBS) program 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 XXXII, Create an Appeal Task in the HHSC Benefits Portal; and
  • an email to CRU at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox that includes:
    • a subject line that reads: STAR+PLUS HCBS Program Appeal Request – XX [applicant’s or member’s first and last name initials];
    • applicant or member name;
    • Medicaid identification (ID) number or Social Security number (SSN);
    • Texas Integrated Eligibility Redesign System (TIERS) Case Number;
    • type of service (i.e., STAR+PLUS HCBS program);
    • specific information requesting the MEPD or TW financial denial 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 MEPD or TW financial denial 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 financial denial case open pending the state fair hearing decision;
    • a copy of Form H2065-D, Notification of Managed Care Program Services; 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 4800-D, Fair Hearing Request Summary, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Refer to Section 7222.1, Continuation of STAR+PLUS HCBS 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 4800-D and the appeal identification number (ID). Once PSU staff receive the notification, PSU staff upload the notification in HEART, following the instructions in Appendix XXXIII, and monitor the appeal until the state fair hearing decision is rendered.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS 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 STAR+PLUS HCBS program 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 7400, 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 Notice 23-3; Effective Aug. 21, 2023

Program Support Unit (PSU) staff must prepare the evidence packet and attend the 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:

  • Form H4803, Notice of Hearing, as a cover sheet;
  • copy of the citation, Title 1 Texas Administrative Code (TAC) Section 353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program;
  • Section 6200.4, Financial Eligibility; and
  • Form H2065-D, Notification of Managed Care Program Services.

Refer to Appendix XXI, Creating an Appeal in TIERS, for more information on PSU staff completion of Form H4800, Fair Hearing Request Summary. 

Continuation of STAR+PLUS HCBS program benefits during a state fair hearing does not apply to SSI denials. Refer to Section 7222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for more information. PSU staff must not return an applicant or member to the STAR+PLUS HCBS program 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 STAR+PLUS HCBS program 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 7400, State Fair Hearing Decision Actions, for more information about notification requirements for required actions following a state fair hearing decision.

7221.4 Other Denial Reasons

Revision 19-13; Effective November 5, 2019

Other denial reasons include, but are 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. PSU staff do not attend state fair hearings related to other denial reasons.

Program Support Unit (PSU) staff complete Form 4800-D, Fair Hearing Request Summary, entering the MCO staff 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 will be required to select "No" in the drop-down menu.

When Form 4800-D 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 STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

PSU staff must not put an applicant or member back on the STAR+PLUS HCBS program 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 reason state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program 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 7400, 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 19-13; Effective November 5, 2019

 

7222.1 Continuation of STAR+PLUS HCBS Program During a State Fair Hearing

Revision 22-1; Effective January 31, 2022

Continuation of STAR+PLUS Home and Community Based Services (HCBS) program benefits during a state fair hearing do not apply for Supplemental Security Income (SSI) denials. For all other denials, the STAR+PLUS HCBS program must continue until the hearings officer issues a decision if the member or authorized representative (AR) files a state fair hearing requesting continued benefits: 

  • within the adverse action notification period of the STAR+PLUS HCBS program 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 XXXIV, STAR+PLUS 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 XXXIII, STAR+PLUS 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: STAR+PLUS HCBS 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 (i.e., STAR+PLUS HCBS program);
    • 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, Managed Care Programs Communication, 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 extend the medical necessity and level of care (MN/LOC) records in the Service Authorization System Online (SASO). PSU staff must not mail Form H2065-D to the member or authorized representative (AR) 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 AR 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 Discontinuation of STAR+PLUS HCBS Program Due to Member Not Requesting a State Fair Hearing

Revision 23-2; Effective May 15, 2023

A member’s STAR+PLUS Home and Community Based Services (HCBS) program services must continue until the effective date of denial noted on Form H2065-D, Notification of Managed Care Program Services. The program denial date is the last day of the month of the current individual service plan (ISP) or the last day of the month in which the adverse action notification period ends, whichever is later. Refer to Section 6200, Adverse Action Notification Period, for additional information.

A member who does not request a state fair hearing with continued benefits before the effective date of the denial will not receive continued STAR+PLUS HCBS program services during the state fair hearing.

SSI members will remain enrolled in STAR+PLUS after STAR+PLUS HCBS termination. SSI members remain eligible for Medicaid 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 19-13; Effective November 5, 2019

 

7231 Uploading State Fair Hearing Evidence Packet to HHSC Benefits Portal

Revision 19-13; Effective November 5, 2019

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, Generation of the 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 in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record, following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions; 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, Notification of Managed Care Program Services); 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 H2060, Needs Assessment Questionnaire and Task/Hour Guide.
  • Pages 11-15 contain policy from the STAR+PLUS Handbook (SPH) that relates directly to the issue in question.
  • Pages 16-20 contain documents signed by the applicant, member or authorized representative (AR) related to individual rights.
  • Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant, member or authorized representative (AR) on March 2."

PSU Example: "I want to offer the following packet as evidence in the state fair hearing filed on the behalf of Ned Flanders.

  • Page 1 contains a copy of Form H4803, Notice of Fair Hearing.
  • Page 2 contains a copy of the Title 1 Texas Administrative Code (TAC) §353.1153, STAR+PLUS Home and Community Based Services (HCBS) Program, that states the STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) 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+PLUS HCBS program services to eligible applicants or members.  
  • Page 3 contains a copy of the SPOPH Section 6200.4, Financial Eligibility, which states an applicant’s or member’s receipt of STAR+PLUS HCBS program services depends on financial eligibility determined by SSI or Medicaid for Elderly and People with Disabilities (MEPD) requirements.
  • Page 4 contains Form H2065-D, which was mailed to the applicant, member or AR 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 19-13; Effective November 5, 2019

After the state fair hearing, the hearings officer renders a decision and sends the written decision to the applicant, member or authorized representative (AR) 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, 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 AR 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 AR requested continued services during the state fair hearing period, PSU staff follow procedures, as described in Section 7400, State Fair Hearing Decision Actions.

7300, Post State Fair Hearing Actions

7310 Action Taken on the State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

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.

7400, State Fair Hearing Decision Actions

Revision Notice 23-3; Effective Aug. 21, 2023

State fair hearing decision terminology used by the hearings officer is defined below:

  • Sustained – This decision type is used when the hearings officer determines HHSC’s action was appropriate per policy and law. 
  • Sustained with Instructions – This decision type is used when the hearings officer determines HHSC’s action was appropriate per policy and law, however new information has been provided and more action is required.
  • Reversed – This decision type is used when the hearings officer determines HHSC’s action was not appropriate per policy and law, and HHSC is ordered to approve or reinstate services.

7410 Sustained State Fair Hearing Decision

Revision 24-2; Effective May 21, 2024

No action is required from Program Support Unit (PSU) staff on sustained fair hearing decisions for applicants and members who did not request continued benefits.

PSU staff must complete the following activities within two business days from the hearings officer’s decision to sustain the termination of a member who received continued STAR+PLUS Home and Community Based Services (HCBS) program benefits:

  • upload Form H2067-MC, Managed Care Programs Communication (PDF), Managed Care Programs Communication (PDF), to the MCOHub notifying the managed care organization (MCO) that the:
    • hearing decision sustained the action on appeal; and
    • MCO must deliver services through the STAR+PLUS HCBS program termination effective date;
  • terminate the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) using the termination date noted in Section 7411, Sustained Decision – Termination Effective Date;
  • close the Community Services Interest List (CSIL) record if the record is open;
  • email the Centralized Representation Unit (CRU) Unit staff at the Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES) Fair Hearings mailbox for medical assistance only (MAO) members; 
    • the email to the CRU Unit must include the following information:
      • an email subject line that states: “Sustained Denial for STAR+PLUS HCBS – Appeal ID ####### [Appeal ID number] for XX [first letter of the member's first and last name]”;
      • the member's name;
      • Medicaid identification (ID) number;
      • the type of request for example notification of sustained denial of the STAR+PLUS HCBS program; 
      • the type of service such as STAR+PLUS HCBS program;
      • HHSC Benefits Portal appeal ID number;
      • the Texas Integrated Eligibility Redesign System (TIERS) case number;
      • STAR+PLUS HCBS program termination effective date; and
      • the state fair hearing decision;
  • upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document and close the HEART case record.

PSU staff do not send Form H2065-D, Notification of Managed Care Program Services (PDF), Notification of Managed Care Program Services (PDF), to notify the applicant, member, or authorized representative (AR) of a sustained denial or termination.

7411 Sustained Decision – Termination Effective Date

Revision 19-13; Effective November 5, 2019

When the STAR+PLUS Home and Community Based Services (HCBS) program is terminated at reassessment because the 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, STAR+PLUS HCBS program 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

ExampleConditionsOriginal MN or ISP Expiration DateNew Expiration DateHearings Officer Decision DateFinal MN or Expiration Date
1Hearings officer decision is more than 30 days from the original expiration date.1/31/185/31/1811/30/171/31/18
2Hearings officer decision is less than 30 days from the original expiration date.1/31/185/31/181/15/182/28/18
3Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date.1/31/185/31/182/15/183/31/18
4Hearings officer decision assigns a specific expiration date.1/31/185/31/18Hearings officer decision was for MN or ISP to expire on 2/15/18.2/18/18
5Hearings officer decision assigns a specific expiration date that occurs in the future.1/31/185/31/18Hearings officer decision was for MN or ISP to expire on 2/28/18.2/18/18
6Hearings officer decision assigns a specific expiration date that occurred in the past.1/31/185/31/18Hearings officer decision was for MN or ISP to expire on 12/31/17.1/31/18

7420 Reversed State Fair Hearing Decision

Revision 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must notify the managed care organization (MCO) of the hearings officer’s decision to reverse the denial or termination of STAR+PLUS Home and Community Based Services (HCBS) program within two business days by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions. PSU staff must notate the following on Form H2067-MC:

  • STAR+PLUS HCBS program services are to continue as directed in the hearings officer’s decision, as applicable; and
  • the MCO must upload a new ISP to TxMedCentral or to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), as applicable.

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

  • manually generate Form H2065-D, Notification of Managed Care Program Services;
    • for all applicants, the ISP begin date will be the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV;
  • ensure the ISP is updated in the Service Authorization System Online (SASO) with the correct effective dates by following the instructions in Section 9000, Service Authorization System Online Help File;
  • for medical assistance only (MAO) applicants, notify Enrollment Resolution Services (ERS) Unit staff by email. The email to ERS Unit staff must include:
    • a subject line that reads: Reversed Hearing Decision – STAR+PLUS HCBS Appeal for XX [first letter of the applicant’s first and last name]. For example, the email subject line for a STAR+PLUS HCBS program termination reversal for Ann Smith would be “Reversed Hearing Decision – STAR+PLUS HCBS Appeal for AS”;
    • the applicant’s name;
    • Medicaid identification (ID) number or Social Security number (SSN);
    • Health and Human Services Commission (HHSC) Benefits portal Appeal ID number;
    • Texas Integrated Eligibility Redesign System (TIERS) case number;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • TIERS Medicaid eligibility effective date;
    • TIERS managed care effective date;
    • Form H2065-D; and
    • the state fair hearing decision;
  • for MAO applicants, notify Centralized Representation Unit (CRU) staff by email at the HHSC Access and Eligibility Services (AES) Fair Hearings mailbox. The email to CRU staff must include:
    • o    a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the applicant’s first and last name];
    • o    the applicant’s name;
    • o    Medicaid ID number or SSN;
    • o    type of request (i.e., continue or reinstate Medicaid eligibility); 
    • o    type of service (i.e., STAR+PLUS HCBS program);
    • o    HHSC Benefits portal Appeal ID number;
    • o    TIERS case number;
    • o    TIERS Medicaid eligibility effective date;
    • o    Form H1746-A , MEPD Referral Cover Sheet; 
    • o    Form H2065-D; and
    • o    the state fair hearing decision;
  • upload all applicable documents to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record following the instructions in Appendix XXXIII , STAR+PLUS 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 receipt of the ISP:

  • electronically generate Form H2065-D in the TMHP LTCOP;
    • for a member who did not receive continued benefits, the ISP begin date will be the first day of the month following the fair hearings officer’s decision, unless otherwise specified by the hearings officer;
    • for a member who did receive continued benefits, the ISP begin date will be the first day of the month following the termination date;
  • mail Form H2065-D to the member;
  • ensure the ISP is updated in SASO with the correct effective dates by following the instructions in Section 9000; 
  • for MAO members, notify ERS Unit staff by email. The email to ERS Unit staff must include:
    • a subject line that reads: Reversed Program Hearing Decision - STAR+PLUS HCBS Program - Appeal – XX [first letter of the member’s first and last name];
    • the member’s name;
    • Medicaid ID number;
    • HHSC Benefits portal Appeal ID number;
    • TIERS case number;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • TIERS Medicaid eligibility effective date;
    • TIERS managed care effective date;
    • Form H2065-D; and
    • the state fair hearing decision;
  • for MAO members, notify CRU staff by email at the HHSC AES Fair Hearings mailbox. The email to CRU staff must include:
    • a subject line that reads: Reinstatement of Benefits for STAR+PLUS HCBS Program – XX [first letter of the member’s first and last name];
    • the member’s name;
    • Medicaid ID number;
    • type of request (i.e., continue or reinstate Medicaid eligibility); 
    • type of service (i.e., STAR+PLUS HCBS program);
    • HHSC Benefits portal Appeal ID number;
    • TIERS case number;
    • TIERS Medicaid eligibility effective date;
    • Form H1746-A; 
    • Form H2065-D; and
    • the state fair hearing decision;  
  • upload all applicable documents to the HEART case record following the instructions in Appendix XXXIII; and
  • document and close the HEART case record.

7421 Reversed Decision – Effective Date

Revision 19-13; Effective November 5, 2019

When the hearings officer’s decision reverses the denial of STAR+PLUS Home and Community Based Services (HCBS) program eligibility, the effective date Program Support Unit (PSU) staff enter on Form H2065-D, Notification of Managed Care Program Services is:

  • for applicants, the first of the month following the hearings officer’s decision; or
  • for members at reassessment, 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 B of 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 Centralized Representative Unit (CRU).

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

7422 New Assessment Required by State Fair Hearing Decision

Revision 19-13; Effective November 5, 2019

If the hearings officer’s decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Medical Necessity and Level of Care (MN/LOC) Assessment, or Form H6516, Community First Choice Assessment, the state fair hearing is closed, pending the results of the new assessment. Program Support Unit (PSU) staff must notify the applicant, member or authorized representative (AR) 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 AR may appeal the results of the new assessment. If the applicant, member or AR chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, on Form 4800-D, 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 AR 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 STAR+PLUS Home and Community Based Services (HCBS) program 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/LOC Assessment, which results in another MN denial. PSU staff send a notice to the member or AR informing him or her of the MN denial. The member or AR then requests 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 AR 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. 

7423 Request to Withdraw a State Fair Hearing

Revision 19-13; Effective November 5, 2019

An applicant, member or authorized representative (AR) 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 AR contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the applicant, member or AR 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 AR 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 AR and must be made to the hearings officer.

If the applicant, member or AR 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 AR 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.

7500, Roles and Responsibilities of HHSC Hearings Officer

Revision 19-13; Effective November 5, 2019

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

  • notify all hearing participants of the date and time of the state fair hearing;
  • prepare a final order disposing of a case through withdrawal and send copies of this order to the applicant, member or authorized representative (AR) and Program Support Unit (PSU) staff upon written notification from the applicant, member or AR to withdraw a state fair hearing;
  • conduct the state fair hearing;
  • consider all testimony and exhibits in making a decision;
  • reserve the right to hold a hearing record open after a state fair hearing to obtain additional information;
  • render a state fair hearing decision; and
  • send a written copy of all state fair hearing decisions to the applicant, member or AR, Texas Medicaid & Healthcare Partnership (TMHP) and PSU staff within five days of making the decision.

8100, Home and Community Based Services

8110 Program Overview

Revision 21-2; Effective March 10, 2021

 

8111 Service Introduction

Revision 21-2; Effective March 10, 2021

The service array under the STAR+PLUS Home and Community Based Services (HCBS) program is designed to offer home and community-based services as cost-effective alternatives to institutional care in Medicaid certified nursing facilities (NFs). Eligible members receive services according to their specific needs, as defined by an assessment process, based on informed choice and through a person-centered process.

Agencies contracted with managed care organizations (MCOs) provide services to members living in their own homes, foster homes, assisted living facilities (ALFs) and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the MCOs, as identified in Section 8113, General Requirements for MCOs, and in accordance with the ISP.

8112 Service Locations for STAR+PLUS HCBS Program

Revision 21-2; Effective March 10, 2021

All services through the STAR+PLUS Home and Community Based Services (HCBS) program, except minor home modifications (MHMs), can be provided to members in locations of their choice. Nursing and therapy services, adaptive aids (including dental) and medical supplies may be provided to a STAR+PLUS HCBS program member residing in an assisted living facility (ALF) contracted to provide STAR+PLUS HCBS program services. Per Title 42 of the Code of Federal Regulations (CFR), Subpart K, §441.530(a)(2), the following locations are excluded from STAR+PLUS HCBS program service locations, with the exception of out-of-home respite care:

  • nursing facilities (NFs);
  • psychiatric hospitals;
  • intermediate care facilities for individuals with intellectual disabilities or related conditions (ICF/IIDs);
  • hospitals providing long term care (LTC); and
  • locations that have the qualities of an institution (e.g., rehabilitation facility, prisons, jails, behavioral health facility).

8113 General Requirements for MCOs

Revision 21-2; Effective March 10, 2021

The managed care organization (MCO) must coordinate and authorize the array of services in accordance with Form H1700-1, Individual Service Plan (Pg. 1). Services include:

  • personal assistance services (PAS);
  • nursing services;
  • physical therapy (PT);
  • occupational therapy (OT);
  • speech therapy (ST);
  • cognitive rehabilitation therapy (CRT);
  • adaptive aids;
  • medical supplies;
  • minor home modifications (MHMs);
  • Emergency Response Services (ERS);
  • assisted living (AL);
  • adult foster care (AFC);
  • home delivered meals (HDM);
  • dental services;
  • transition assistance services (TAS);
  • respite care;
  • employment assistance (EA); and
  • supported employment (SE).

The MCO must identify, coordinate and when applicable, authorize available Medicaid services, Medicare and other third-party resources (TPRs) before authorizing those services on the member's individual service plan (ISP). Refer to specific service descriptions for exceptions or limitations.

8114 Individual Service Plan

Revision 23-2; Effective May 15, 2023

The managed care organization (MCO) must authorize all services identified on the individual service plan (ISP). The ISP is composed of the following documents:

  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-3, Individual Service Plan – Signature Page;
  • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum;
  • Form H6516, Community First Choice Assessment; or
  • Other forms and assessments related to the services provided.

The MCO must upload Form H1700-1 to TxMedCentral if the MCO manually generates Form H1700-1. The MCO is not required to upload Form H1700-1 to TxMedCentral if the MCO electronically generates Form H1700-1 through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The MCO maintains all other forms in the member case file.

8115 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

8116 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

8117 Reserved for Future Use

Revision 23-2; Effective May 15, 2023

 

8118 Personal Assistance Services

Revision 23-2; Effective May 15, 2023

Personal assistance services (PAS) assist members perform activities of daily living (ADLs) based on the member’s needs. PAS includes assistance with the performance of the ADLs and instrumental activities of daily living (IADLs) necessary to maintain the home in a clean, sanitary and safe environment.

Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service. Federal and state rules prohibit a spouse from being the paid PAS provider.

8118.1 Description of Personal Assistance Services

Revision 21-2; Effective March 10, 2021

Personal assistance services (PAS) include the following:

  • assistance with the basic self-care tasks known as activities of daily living (ADLs). These include, but are not limited to, self-feeding, dressing, bathing, personal hygiene and grooming, transferring and going to the toilet;
  • assistance with instrumental activities of daily living (IADLs).  These are activities that allow an individual to live independently in the community, such as cleaning and maintaining the house, preparing meals, shopping for groceries and taking prescribed medications (this is not an all-inclusive list);
  • providing extension of therapy services;
  • providing assistance with ambulation and balance;
  • assisting with medications that are normally self-administered;
  • performing health maintenance activities, as defined by the Texas Board of Nursing (BON);
  • performing nursing tasks delegated and supervised by a registered nurse (RN), in accordance with the Texas BON rules;
  • escorting the member on trips to obtain medical diagnosis, treatment or both; and
  • providing protective supervision.

The managed care organization (MCO) must authorize and ensure the provision of PAS, as identified on Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum, and authorize PAS, as applicable, to members living in their own homes or other community settings.

Activities purchased under PAS are limited to the member’s personal space and solely for the member’s personal needs. The following examples of services not reimbursable under the STAR+PLUS Home and Community Based Services (HCBS) program are:

  • taking care of household non-service related pets;
  • ironing;
  • moving furniture;
  • cleaning windows; and
  • performing yard work other than yard hazard removal.

Shopping

Shopping is intended for the purchase of groceries, medications or other items that support the health, safety and well-being of a member. This may be done by the attendant on behalf of the member or to accompany the member to assist with this task. Neither the provider nor the attendant can charge the member for transportation costs incurred in the performance of this task.

Ambulation

Ambulation is a personal care task that involves non-skilled assistance with walking or transferring while taking the usual precautions for safety (that is, standby assistance, gentle support of an elbow for balance or assuring balance of a walker). This does not involve nursing intervention. No special precautions are needed other than for safety measures.

To facilitate safe member ambulation or movement, the attendant may need to ensure safe pathways throughout the home for the member. Examples include those who use wheelchairs, walkers or crutches, or for members with visual impairment. The attendant care provider or member (or member's authorized representative (AR)) addresses this activity during orientation and on an ongoing basis for an attendant who provides services to a member needing assistance.

The member’s primary care provider (PCP) may request specific ambulation orders. If ambulation is authorized as a nursing task, the MCO service coordinator must not authorize ambulation as a non-skilled task on Form H6516, Form H2060 and any addendums to Form H2060. Authorizing ambulation as a nursing task and at the same time as a non-skilled task is a duplication of services. When completing the functional assessment on Form H2060 and any addendums to Form H2060, the MCO service coordinator must consider the member’s need for ambulation. If it appears the member needs both skilled and non-skilled ambulation assistance, the MCO service coordinator must document in the case record why and how the member requires both. The MCO service coordinator can approve both if there is no duplication.

Escort

Escorting is for health care-related appointments and does not include the direct transportation of the member, or the receipt or exchange of health information by the attendant. Escort services may be provided for safety needs, to enter or exit a building, or to remain safe during the wait time while attending medical appointments. Transportation for Medicaid members to Medicaid appointments is available in every county through the Medical Transportation Program (MTP). Transportation is not included as an activity in the escort task.

Protective Supervision

The purpose of protective supervision is to assure the health and welfare of a member with a cognitive impairment, memory impairment or physical weakness. Protective supervision is authorized by the MCO and assures supervision of the member during instances in which the member’s informal support is unavailable.

Protective supervision is supervision only and does not include the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the member from injury due to his or her cognitive or memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn himself or herself, or try to walk and then fall. Protective supervision is not routinely authorized for members who can safely live on their own, nor is it intended to provide 24-hour care. Protective supervision is not a benefit of Community First Choice (CFC) and can be on a member’s individual service plan (ISP), even if the member receives CFC.

Exercise

A member may request, or a physician may order, assistance with walking as a form of exercise. A member must be ambulatory for exercise to be an authorized PAS activity.

Therapy Extension

Licensed therapists may choose to instruct the PAS attendant on the proper way to assist the member in follow-up of therapy sessions. This assistance or support provides reinforcement of instruction and aids in the rehabilitative process. Therapy extension is documented on Form H2060-A.

8118.2 Personal Assistance Services Attendants

Revision 21-2; Effective March 10, 2021

Personal assistance services (PAS) are performed by personal care attendants who:

  • are not themselves recipients of PAS;
  • are employed by a managed care organization (MCO) contracted provider or employed by the member or the employer of record under the Consumer Directed Services (CDS) option;
  • are not the spouse of member;
  • perform all of the services available within his or her scope of competency;
  • may serve as backup attendants to initiate services, prevent a break in service and provide ongoing service;  
  • are required to provide services that meet a member’s health and safety needs; and
  • if applicable, meet additional eligibility requirements under the CDS option.

8300, Therapy Services

Revision 21-2; Effective March 10, 2021

Therapy services purchased through the STAR+PLUS Home and Community Based Services (HCBS) program are long-term services and supports (LTSS) and do not replace a member’s acute care benefit. Therapy services include the evaluation, examination and treatment of physical, functional, cognitive, speech and hearing disorders and/or limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of the therapist’s state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic. If therapy is provided outside the member's residence based on the member's choice, the member is responsible for providing his or her own transportation or accessing the Medicaid Medical Transportation Program (MTP).

If therapy is provided outside the member's residence because of the convenience of the provider, the provider is responsible for providing the member's transportation. If a member resides in an adult foster care (AFC) or an assisted living (AL) setting and therapy is provided in an outpatient center or clinic (refer to Section 8112, Service Locations for STAR+PLUS HCBS Program), the AL or AFC provider is responsible for arranging the transport or directly transporting the member.

Occupational therapy (OT), physical therapy (PT), speech therapy (ST) and cognitive rehabilitative therapy (CRT) services are covered by the STAR+PLUS HCBS program only after the member has exhausted his or her therapy benefit under Medicare, Medicaid or other third-party resources (TPR). Providers contracted with the managed care organization (MCO) must provide the OT, PT, ST and CRT services as identified on the member's individual service plan (ISP). Individuals providing therapy services must be licensed in Texas in their profession or be licensed or certified as assistants and employed directly or through sub-contract or personal service agreements with a provider, or through the Consumer Directed Services (CDS) option.

PT is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed PT assistant directly supervised by a licensed physical therapist. PT is the evaluation, examination and utilization of exercises, rehabilitative procedures, massage, manipulations and physical agents including, but not limited to, mechanical devices, heat, cold, air, light, water, electricity and sound in the aid of diagnosis or treatment.

OT consists of interventions and procedures to promote or enhance safety and performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. It is provided by a licensed occupational therapist or a certified OT assistant directly supervised by a licensed occupational therapist.

ST is defined as the evaluation and treatment of impairments, disorders or deficiencies related to an individual's speech and language. The scope of speech, hearing and language therapy services offered to STAR+PLUS HCBS program participants exceeds the Texas state plan as the service in this context is available to adults. It is provided by a speech-language pathologist or a licensed associate in speech-language pathology under the direction of a licensed speech-language pathologist.

8310 Cognitive Rehabilitation Therapy

Revision 21-2; Effective March 10, 2021

Cognitive rehabilitative therapy (CRT) is a service that assists a member in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells or chemistry in order to enable the member to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. CRT is provided in accordance with the individual service plan (ISP) developed by the assessor, and includes reinforcing, strengthening or reestablishing previously learned patterns of behavior or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. Qualified providers include:

  • Psychologists licensed under Texas Occupations Code, Title 3, Chapter 501;
  • Speech and language pathologists licensed under Texas Occupations Code, Title 3, Subtitle G, Chapter 401; or
  • Occupational therapists licensed under Texas Occupations Code, Title 3, Subtitle H, Chapter 454. 

8320 Initiation of Assessment and Therapy

Revision 21-2; Effective March 10, 2021

A therapy assessment is initiated upon member request, recommendation from the member’s primary care provider (PCP) or managed care organization (MCO) service coordinator. The MCO service coordinator must coordinate with the member to select a provider for the assessment. The Medical Necessity and Level of Care (MN/LOC) Assessment must be submitted by the provider for the MCO service coordinator to authorize service hours based on physician orders and MN review. Any therapy for the management of a chronic condition must be included on the individual service plan (ISP).

8330 Responsibilities of Licensed Therapists in STAR+PLUS HCBS Program

Revision 21-2; Effective March 10, 2021

Responsibilities of the licensed therapists include the following:

  • assessing the member's need for therapy, adaptive aids and minor home modifications (MHMs);
  • delivering direct therapy as authorized in the individual service plan (ISP);
  • supervising delivery of therapy rendered by the therapy assistant as authorized in the ISP;
  • informing the physician and other team members of changes in the member's health status requiring an ISP change;
  • training the member’s attendant or caregiver to extend therapeutic interventions;
  • training the member to use adaptive aids; and
  • participating in interdisciplinary team meetings, when appropriate and requested by the MCO.  

8400, Adaptive Aids and Medical Supplies

Revision 21-2; Effective March 10, 2021

Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their ability to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which the member lives. Adaptive aids and medical supplies are reimbursed with STAR+PLUS Home and Community Based Services (HCBS) program funds, when specified in the individual service plan (ISP), with the goal of providing the individual a safe alternative to nursing facility (NF) placement.

Adaptive aids and medical supplies may also include items necessary for life support, ancillary supplies and equipment necessary for the proper functioning of such items, and durable and non-durable medical equipment not available under the Texas state plan, such as vehicle modifications, service animals and supplies, environmental adaptations, aids for daily living, reachers, adapted utensils and certain types of lifts.

The annual cost limit of this service is $10,000 per ISP year. The managed care organization (MCO) may exceed the $10,000 cost limit; however, the MCO must not include any costs over the $10,000 on any cost reports, claims, encounters or financial statistical reports (FSR).

Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member’s provider for this service if the relative or legal guardian meets the requirements for this type of service.

Adaptive aids and medical supplies are limited to the most cost-effective items that:

  • meet the member's needs;
  • directly aid the member to avoid premature NF placement; and
  • provide NF residents an opportunity to return to the community.

8410 List of Adaptive Aids and Medical Supplies

Revision 21-2; Effective March 10, 2021

Adaptive aids and medical supplies are covered by the STAR+PLUS Home and Community Based Services (HCBS) program only after the member has exhausted Texas state plan benefits and any third-party resources (TPRs) including product warranties, Medicare and Medicaid the member is eligible to receive.

If a vehicle modification costs $1,000 or more and the vehicle has been driven more than 75,000 miles or is over four years old, the managed care organization (MCO) contracted provider must:

  • obtain a written evaluation by an experienced mechanic to ensure the sound mechanical condition of all major components of the vehicle;
  • document the experience of the mechanic doing the evaluation; and
  • include the actual cost of the written evaluation as part of the invoice cost not to exceed $150.

Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of, but are not limited to, the following:

  • lifts:
    • wheelchair porch lifts;
    • hydraulic, manual or other electronic lifts;
    • stairway lifts;
    • bathtub seat lifts;
    • ceiling lifts with tracks;
    • transfer bench;
  • mobility aids, including batteries and chargers:
    • manual or electric wheelchairs and necessary accessories;
    • customized wheelchair with documentation of cost effectiveness;
    • three- or four-wheel scooters;
    • mobility bases for customized chairs;
    • braces, crutches, walkers and canes;
    • forearm platform attachments for walkers and motorized or electric wheelchairs;
    • prescribed prosthetic devices;
    • prescribed orthotic devices, orthopedic shoes and other prescribed footwear, including diabetic shoes if the member does not have Medicare and there is a documented medical need and a physician order for the shoes;
    • diabetic slippers or socks;
    • prescribed exercise equipment and therapy aids;
    • portable ramps;
  • respiratory aids:
    • ventilators or respirators;
    • back-up generators;
    • oxygen containers or concentrators, and related supplies;
    • continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines, including headgear;
    • nebulizers;
    • portable air purifiers and filters for a member with chronic respiratory diagnosis such as asthma, Chronic Obstructive Pulmonary Disease (COPD), bronchitis or emphysema;
    • suction pumps;
    • incentive spirometers and peak flow meters;
  • positioning devices:
    • standing boards, frames and customized seating systems;
    • electric or manual hospital beds, tilt frame beds and necessary accessories;
    • hospital beds, including electric controls, manual cranks or other items related to the use of the bed (Medicare or Medicaid can cover hospital beds, specialty mattresses and specialty hospital bed sheets for skin breakdown);
    • replacement mattresses;
    • egg crate mattresses, sheepskin and other medically related padding;
    • wheelchair cushions;
    • elbow, knee and heel protectors and hand rolls for positioning;
    • arm slings, arm braces and wrist splints;
    • abdominal binders;
    • trapeze bars;
  • communication aids (including repair, maintenance and batteries):
    • augmentative communication devices:
      • direct selection communicators;
      • alphanumeric communicators;
      • scanning communicators;
      • encoding communicators;
      • speaker and cordless telephones for persons who cannot use conventional telephones;
    • speech amplifiers, aids and assistive devices;
    • interpreters;
  • control switches- or pneumatic switches and devices:
    • sip and puff controls;
    • adaptive switches or devices;
  • environmental control units:
    • locks;
    • electronic devices;
    • voice-activated, light-activated and motion-activated devices;
  • medically necessary durable medical equipment (DME) not covered in the state plan for the Texas Medicaid Program;
  • temporary lease or rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment;
  • payment of premium deductibles and co-insurance (for items covered under the STAR+PLUS HCBS program), including rentals for Medicare or TPR, if not covered under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs;
  • modifications or additions to primary transportation vehicles:
    • van lifts;
    • driving controls:
      • brake or accelerator hand controls;
      • dimmer relays or switches;
      • horn buttons;
      • wrist supports;
      • hand extensions;
      • left-foot gas pedals;
      • right turn levers;
      • gear shift levers;
      • steering spinners;
    • medically necessary air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate temperature;
    • removal or placement of seats to accommodate a wheelchair;
    • installation, adjustments or placement of mirrors to overcome visual obstruction of wheelchair in vehicle;
    • raising the roof of the vehicle, lowering the floor or modifying the suspension of the vehicle to accommodate an individual riding in a wheelchair;
    • installation of frames, carriers, lifts for transporting mobility aids;
    • installation of trailer hitches for trailers used to transport wheelchairs or scooters;

Note: If the adaptive aid is a vehicle modification, the program provider must obtain written approval from the vehicle’s owner before making the modification. The owner must sign and date the approval. The MCO must maintain documentation that the contracted provider ensured the specifications for a vehicle modification included information on the vehicle to be modified, including:

  • the year and model of the vehicle;
    • a determination that the vehicle is the member’s primary vehicle;
    • proof of ownership of the vehicle;
    • current state inspection and registration for the vehicle;
    • any required state insurance for the vehicle;
    • mileage of the vehicle;
    • an itemized list of parts and accessories, including prices;
    • an itemized list of required labor, including labor charges; and
    • warranty coverage;
  • sensory adaptations:
    • corrective lenses including eyeglasses not covered by the Texas state plan;
    • hearing aids not covered by the state plan;
    • auditory adaptations to mobility devices; and
  • adaptive equipment for activities of daily living (ADLs):
    • assistive devices:
      • reachers;
      • stabilizing devices;
      • weighted equipment;
      • holders;
      • feeding devices, including:
        • electric self-feeders; and
        • food processors and blenders – only for members with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances;
    • variations of everyday utensils:
      • shaped, bent, built-up utensils;
      • long-handled equipment;
      • addition of friction covering;
      • coated feeding equipment;
    • medication reminder systems, including those for the visually disabled;
    • walking belts and physical fitness aids;
    • specially adapted kitchen appliances;
    • toilet seat reducer rings unless member resides in an assisted living facility (ALF);
    • bedside commodes;
    • hand-held shower sprays unless member resides in an ALF;
    • shower chairs unless member resides in ALF or residential care facility;
    • electric razors;
    • electric toothbrushes;
    • water picks;
    • service animals and maintenance including veterinary expenses;
    • over-bed tray tables unless member resides in an ALF;
    • safety devices, such as:
      • safety padding;
      • helmets;
      • elbow and knee pads;
      • visual alert systems;
    • medically necessary heating and cooling equipment for members with respiratory or cardiac problems, people who cannot regulate temperature or people who have conditions affected by temperature;
    • one window or portable air conditioner, including wiring, for a member’s main living area, such as a bedroom;
    • medical supplies necessary for therapeutic or diagnostic benefits for:
      • tracheostomy care;
      • decubitus care;
      • ostomy care;
      • pulmonary, respirator or ventilator care; and
      • catheterization.

Other types of supplies include:

  • incontinence supplies, including diapers, disposable or washable bed pads, briefs, protective liners, pull ups, wipes, moisture protective mattress covers, moisture barrier cream, regular or antiseptic wipes (if a medical need is documented), sheets, towels and washcloths (if medically necessary);
  • nutritional supplements;
  • enteral feeding formulas and supplies;
  • mouth swabs and toothettes;
  • diabetic supplies (strips, lancelets and syringes);
  • Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repairs;
  • stethoscopes, blood pressure monitors and thermometers for home use;
  • blood glucose monitors;
  • medical alert bracelets;
  • sharps or biohazard containers;
  • anti-embolism hose or stockings, such as thromboembolic disease hose; and
  • approved enemas, if not available through the state plan or other TPR.

Other

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare or Medicaid can cover hospital beds and specialty mattresses. Specialty sheets, such as hospital bed sheets, may be covered.

The STAR+PLUS HCBS program will pay for a Geri-chair if the member is alert, oriented and able to remove the tray table without assistance and as desired. Otherwise, the Geri-chair is considered a restraint and the STAR+PLUS HCBS program does not pay for restraints.

Gloves

Gloves may be purchased through the STAR+PLUS HCBS program for family or caregiver use in the care of a member with incontinence or if the member has an active infectious disease that is transmitted through body fluids. Examples of active infectious diseases that qualify are Methicillin-resistant Staphylococcus aureus (MRSA) and hepatitis. Gloves may be purchased for family or caregiver use to provide wound care to protect the member. Documentation by the MCO contracted provider must support the need of gloves to be left at the residence and for family or caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his or her approval.

Adaptive Aid Exclusions

The following are examples of items that may not be purchased using STAR+PLUS HCBS program funds. These items include, but are not limited to:

  • hot water heater;
  • combination heater, light and exhaust fan;
  • heating and cooling system filters;
  • non-adapted appliances, such as refrigerators, stoves, dryers, washing machines and vacuum cleaners;
  • water filtration systems;
  • central air conditioning and heating;
  • multiple air conditioning units to cover an individual's residence;
  • non-adapted home furnishings to include (except as allowed through transition assistance services (TAS) or Supplemental Transition Support):
    • cooking utensils;
    • non-hospital bed mattresses and springs, including Adjustamatic, Craftmatic, Tempur-Pedic®, Posturepedic and Sleep Number® beds;
    • pillows (excluding neck pillows and support wedge pillows);
  • electrical heating elements (heating pads, electric blankets);
  • recreational items, equipment and supplies including:
    • bicycles and tricycles (two, three or four wheels);
    • helmets for recreational purposes;
    • trampolines;
    • swing sets;
    • bowling and fishing gear;
    • karaoke machines;
    • entertainment systems;
    • off-road recreational vehicles;
  • memberships to gyms, spas, health clubs, or other exercise facilities;
  • communication items, including:
    • telephones (standard, cordless or cellular);
    • pagers;
    • pre-paid minute cards;
    • monthly service fees;
  • computers for the following justifications:
    • educational purposes;
    • self-improvement/employment purposes;
    • improvement of general computer skills;
    • internet and email access;
    • games and fun/craft activities;
  • office equipment and supplies to include:
    • fax machines;
    • printers or copiers;
    • scanners;
    • internet and email services;

Note: An individual accessing the Consumer Directed Services (CDS) option may purchase office equipment and supplies through the CDS budget.

  • gloves for universal precautions, or gloves that are used by MCO contracted provider, an adult foster care (AFC) provider or any contracted provider staff;
  • personal items for activities of daily living (ADLs), such as hygiene products including soap, waterless soap, toothbrush, toothpaste, deodorant, powder, shampoo, lotions (except moisture barrier products), feminine products (except when documented for use as an incontinent supply), manual razors, washcloths, towels, bibs and first-aid supplies;
  • clothing items;
  • food;
  • bottled water (for drinking and cooking);
  • nutritional drinks and products, such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, nutrition and protein bars, breakfast cereals;
  • vitamins, minerals and herbal supplements and over-the-counter drugs;
  • title, license and registration for trailers or vehicles;
  • wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports;
  • vehicle repairs, as part of normal maintenance; repairs are part of normal vehicle maintenance and cannot be covered. Installation of heavy-duty shocks as required by a lift installation may be included as part of the vehicle modification; trailers (including taxes) for transporting wheelchairs or scooters;
  • experimental medical treatment and therapies, such as equestrian therapy; and
  • installation of gas or propane lines.

8420 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

8430 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

8440 Reserved for Future Use

Revision 22-3; Effective Sept. 27, 2022

 

8450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies

Revision 21-2; Effective March 10, 2021

 

8451 Time Frames for Adaptive Aids

Revision 21-2; Effective March 10, 2021

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized (except for vehicle modifications) to purchase the adaptive aid, counting from either the effective date of the individual service plan (ISP) on Form H1700-1, Individual Service Plan (Pg. 1), or the date the form is received, whichever is later. If delivery is not possible in 14 business days, the MCO will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO ISP folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, documenting the reason for the delay.

The MCO must notify the member and document notification of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business day following authorization. If the delivery does not occur by the new proposed date, the MCO must document any further delays, as well as document member notification, until the adaptive aids are delivered. The MCO must authorize a vehicle modification on the effective date of the member’s ISP. The MCO must coordinate with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.

8452 Time Frames for Medical Supplies

Revision 21-2; Effective March 10, 2021

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive STAR+PLUS Home and Community Based Services (HCBS) program services. The provider must deliver medical supplies within five business days from the start date on the individual service plan (ISP). The member’s current supply of these items should be considered. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) before the fifth business day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

If there is an existing supply of medical supplies on the service initiation date, the MCO must write "existing supply of needed medical supplies on hand" in the progress notes as verification that supplies were available to the member and did not require delivery at this time.

Stockpiling of medical supplies must not occur. Supplies, such as incontinence and wound care supplies not covered through Medicaid home health and needed on an ongoing basis, should be delivered so there is no more than a three-month supply in the member's home at one time.

8500, Dental Services

Revision 21-2; Effective March 10, 2021

Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Home and Community Based Services (HCBS) program members with licensed and enrolled dentists.

The MCO must discuss with the STAR+PLUS HCBS program member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through the STAR+PLUS HCBS program. If dental services are on the individual service plan (ISP), the MCO must authorize and coordinate a referral to a dental provider within 90 days of request by the member, unless there is documentation that the member requested a later date.

8510 Allowable Dental Services

Revision 21-2; Effective March 10, 2021

Allowable dental services include:

  • emergency dental treatment procedures necessary to control bleeding, relieve pain and eliminate acute infection;
  • preventative procedures required to prevent the imminent loss of teeth;
  • treatment of injuries to the teeth or supporting structures;
  • dentures and the cost of fitting and preparing for dentures, including extractions, molds, etc.; and
  • routine and preventative dental treatment.

The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by the STAR+PLUS Home and Community Based Services (HCBS) program when no other financial resource for such services is available and when all other available resources are exhausted, with the exception of value-added services (VAS). VAS are not required to be used prior to STAR+PLUS HCBS program dental benefit. VAS vary by MCO.

Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this type of service. Payments for dental services are not made for cosmetic dentistry.

The annual cost limit of this service is $5,000 per individual service plan (ISP) year. The $5,000 cost limit may be waived by the MCO upon request of the member only when the services of an oral surgeon are required.

8600, Minor Home Modifications

Revision 21-2; Effective March 10, 2021

Minor home modifications (MHMs) are those physical adaptations to a member’s home, required by the individual service plan (ISP), that are necessary to ensure the member's health, welfare and safety or that enable the member to function with greater independence in the home. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities or installation of specialized electric and plumbing systems that are needed to accommodate the medical equipment and supplies necessary for the member’s welfare. Excluded are those adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the member, such as carpeting, roof repair, central air conditioning, etc. Adaptations that add to the total square footage of the home are excluded from this benefit.

All services are provided in accordance with applicable state or local building codes. Modifications are not made to settings that are leased, owned or controlled by providers contracted with the managed care organization (MCO). The Texas Health and Human Services Commission (HHSC) allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this type of service.

8610 Responsibilities Pertaining to Minor Home Modifications

Revision 21-2; Effective March 10, 2021

In order to ensure cost-effectiveness in the purchase of minor home modifications (MHMs), the managed care organization (MCO) must:

  • determine and document the needs and preferences of the member for the MHM; and
  • document the necessity for the MHM.

The MCOs have their own policies and procedures in regards to bidding, awarding contracts, doing inspections and completing MHMs.

8620 List of Minor Home Modifications

Revision 21-2; Effective March 10, 2021

The following minor home modifications (MHMs) include the installation, maintenance and repair of approved items not covered by warranty:

  • Purchase of wheelchair ramps;
    • protective awnings over ramps;
  • Modifications or additions for accessible bathroom facilities;
    • wheelchair accessible showers;
    • sink modifications;
    • bathtub modifications;
    • toilet modifications;
    • water faucet controls;
    • floor urinal and bidet adaptations;
    • plumbing modifications and additions to existing structures necessary for accessibility adaptations;
    • turnaround space modifications;
  • Modifications or additions for accessible kitchen facilities;
    • sink modifications;
    • sink cut-outs;
    • turnaround space modifications;
    • water faucet controls;
    • plumbing modifications or additions to existing structures necessary for accessibility adaptations;
    • worktable, work surface adjustments or additions;
    • cabinet adjustments or additions;
  • Specialized accessibility, safety adaptations or additions, including repair and maintenance;
    • door widening;
    • electrical wiring;
    • grab bars and handrails;
    • automatic door openers, doorbells, door scopes, and adaptive wall switches;
    • fire safety adaptations and alarms;
    • medically necessary air filtering devices;
    • light alarms, doorbells for the hearing and visually impaired;
    • floor leveling, only when the installation of a ramp is not possible;
    • vinyl flooring or industrial grade carpet necessary to ensure the safety of the member, prevent falling, improve mobility, and adapt a living space occupied by a member who is unable to safely use existing floor surface;
    • medically necessary steam cleaning of walls, carpet, support equipment and upholstery;
    • widening or enlargement of garage and/or carport to accommodate primary transportation vehicle and to allow persons using wheelchairs to enter and exit their vehicles safely;
    • installation of sidewalk for access from non-connected garage and/or driveway to residence, when existing surface condition is a safety hazard for the person with a disability;
    • porch or patio leveling, only when the installation of a ramp is not possible;
    • safety glass, safety alarms, security door locks, fire safety approved window locks, and security window screens; for example, for persons with severe behavioral problems;
    • security fencing for residence, for those persons with cognitive impairment or persons whose safety would be compromised if they wandered;
    • protective padding and corner guards for walls for members with impaired vision and mobility;
    • recessed lighting with mesh covering and metal dome light covers to compensate for violent aggressive behavior; for example, for persons with autism or mental illness;
    • noise abatement renovations to provide increased sound proofing; for example, for persons with autism or mental illness;
    • door replacement for accessibility only;
    • motion sensory lighting;
    • intercom systems for individuals with impaired mobility; and
    • lever door handles.

Ramps may be installed for improved mobility for use with scooters, walkers, canes, etc., or for members with impaired ambulation, as well as for wheelchair mobility. In some instances and according to supporting documentation, multiple modifications may be needed for accessibility and mobility, such as ramps and hand rails for members with impaired ambulation. There is no limit to the number of wheelchair ramps that can be authorized, provided the total cost does not exceed the cost limit. Documentation must support the justification for additional ramps as related to medical need or health and safety of the member.

Carbon monoxide detectors cannot be purchased under STAR+PLUS Home and Community Based Services (HCBS) program as a "fire safety adaptation and alarm."

Requests for items (or repair of items) or service calls that are considered routine home maintenance and upkeep cannot be approved.

Items that cannot be approved by the managed care organization (MCO) service coordinator include:

  • carpeting (other than industrial grade);
  • newly constructed carports, porches, patios, garages, porticos or decks;
  • electric fences;
  • landscaping and yard work or supplies;
  • roof repair or replacement;
  • gutters;
  • leaky faucet repair;
  • elevators;
  • house painting;
  • electrical upgrades and/or electrical outlets, unless needed to power adapted equipment or a safety hazard exists;
  • air duct cleaning and maintenance; and
  • pest exterminations.

Heating and cooling equipment may be approved as an adaptive aid. Installation of approved heating and cooling equipment is included in the cost of the adaptive aid. Support platforms are frequently used to provide support for cooling equipment installed in home windows. The support platforms attach in a clamp-like manner without fasteners. The cost and installation of support platforms are considered as an adaptive aid. The installation of heating and cooling equipment may require modification of the home (for example, additional wiring or widening of the windows). The modification of the home must be authorized as an MHM.

Flooring applications, including vinyl and industrial carpet, may not be authorized for adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the member.

8630 Minor Home Modification Service Cost Lifetime Limit

Revision 21-2; Effective March 10, 2021

There is a cost lifetime limit of $7,500 per member for this service and $300 yearly for repairs. Once the $7,500 cost limit is reached, only $300 per year per member, excluding associated fees, will be allowed for repairs, replacement or additional modifications. The managed care organization (MCO) is responsible for obtaining cost effective modifications authorized on the member's individual service plan (ISP). The MCO may exceed the $7,500 cost limit; however, the MCO must not include costs over the lifetime limit on any cost reports, claims, encounters or financial statistical reports (FSRs).

If a member changes MCOs, the losing MCO must provide documentation to the gaining MCO related to any minor home modification (MHM) expenditures. Refer to Uniform Managed Care Contract (UMCC) Terms and Conditions, Section 5.06, Span of Coverage, for payment responsibilities.

8640 Landlord Approval for Minor Home Modifications

Revision 21-2; Effective March 10, 2021

When the member has a landlord or when the owner of the home is not the member, written approval prior to the initiation of any requested minor home modification (MHM) must be obtained by the managed care organization (MCO).

8700, Employment Services

8710 Employment Assistance

Revision 21-2; Effective March 10, 2021

Employment assistance (EA) is provided to a member to help the member 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.

In the state of Texas, this service is not available to members receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. 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 (United States Code (U.S.C.) Title 20, §1401 et seq.).

An EA service provider’s credentials must satisfy one of these options:

Option 1:

  • a bachelor's degree in rehabilitation, business, marketing or a related human services field; and
  • six months of documented experience providing services to people with disabilities in a professional or personal setting.

Option 2:

  • an associate's degree in rehabilitation, business, marketing or a related human services field; and
  • one year of documented experience providing services to people with disabilities in a professional or personal setting.

Option 3:

  • a high school diploma or general equivalency diploma (GED); and
  • two years of documented experience providing services to people with disabilities in a professional or personal setting.

8720 Supported Employment

Revision 21-2; Effective March 10, 2021

Supported employment (SE) is assistance provided, in order to sustain 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. SE includes adaptations, supervision, training related to a member’s assessed needs and earning at least minimum wage (if not self-employed). In the state of Texas, this service is not available to members receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. 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 (United States Code (U.S.C.) Title 20, §1401 et seq.).

An SE service provider’s credentials must satisfy one of these options:

Option 1:

  • a bachelor's degree in rehabilitation, business, marketing or a related human services field; and
  • six months of documented experience providing services to people with disabilities in a professional or personal setting.

Option 2:

  • an associate's degree in rehabilitation, business, marketing or a related human services field; and
  • one year of documented experience providing services to people with disabilities in a professional or personal setting.

Option 3:

  • a high school diploma or general equivalency diploma (GED); and
  • two years of documented experience providing services to people with disabilities in a professional or a personal setting.

9100, Initial Service Authorization

Revision 18-0; Effective September 4, 2018

When Program Support Unit (PSU) staff authorize the STAR+PLUS Home and Community Based Services (HCBS) program for an initial service authorization in the Service Authorization System Online (SASO), PSU staff must check or create the following records according to Sections 9110 through 9170:

  • Authorizing Agent – Initial;
  • Enrollment – Initial;
  • Service Plan – Initial;
  • Service Authorization – Initial;
  • Level of Service  – Initial;
  • Diagnosis – Initial; and
  • Medical Necessity – Initial. 

9110 Authorizing Agent - Initial

Revision 24-2; Effective May 21, 2024

Use the authorizing agent record in the Service Authorization System Online (SASO) to register the authorizing agent begin date with an open-ended date for the STAR+PLUS Home and Community Based Services (HCBS) program applicant.

There will normally be one authorizing agent registered in SASO for a STAR+PLUS HCBS program applicant.

Initial individual service plans (ISPs) submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal have a system generated authorizing agent. The TMHP LTC Online Portal interfaces with the SASO and records "STAR+PLUS" in the ‘Authorizing Agent’ field and records the managed care organization (MCO) service coordinator's name in the ‘Name’ field.

The TMHP LTC Online Portal will generate changes to the SASO authorizing agent records for a member with a plan code change during an ISP year where a current or future ISP is in a processed or complete status. In this case, a SASO authorizing agent record is created for the initial ISP with a begin date equal to the new managed care organization (MCO) plan effective date. The SASO authorizing agent record for the transferred ISP is automatically ended with the prior MCO plan enrollment end date.

Program Support Unit (PSU) staff:

  • Do not register an authorizing agent for an electronic ISP.
  • Can create authorizing agent record(s) for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose ISP was not transmitted electronically.
  • Must confirm the authorizing agent registration in SASO.  
  • Are registered as the authorizing agent when an applicant is authorized in SASO.

To register an authorizing agent, record for a STAR+PLUS HCBS program applicant whose ISP requires manual entry, PSU staff must:

  1. Select the Authorizing Agent field in the Case Worker functional area.
  2. Select Add and a blank Authorizing Agent Details record will appear.
  3. Move to the Type field and select CM – Case Manager from the drop-down menu.
  4. Move to the Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Leave the Send to TMHP field at the default selection N - NO.
  6. Move to the Begin Date field and enter the effective date of the ISP period
  7. Leave the End Date field blank.
  8. Move to the Authorizing Agent field and enter STAR+PLUS.
  9. Leave the Agency field at the default selection 324 - DHS.
  10. Move to the Name field and enter the PSU staff’s service area.
  11. Move to the Phone field and enter the phone number of the authorizing agent. Enter the area code, phone number and extension.
  12. Move to the Mail Code field and enter the appropriate Managed Care Organization (MCO) plan code from the table below. Note: Six service areas include Medicare-Medicaid Plans (MMP).
Service AreaMCO Plan NameMCO Plan Code
BexarWellpoint45
Molina46 
Superior47 
Wellpoint MMP4F 
Molina MMP4G 
Superior MMP4H 
DallasMolina9F
Superior Health Plan9H 
Molina MMP9J 
Superior MMP9K 
El PasoWellpoint34
Molina33 
Wellpoint MMP3G 
Molina MMP3H 
HarrisWellpoint7P
United Healthcare7R 
Molina7S 
Wellpoint MMP7Z 
United Healthcare MMP7Q 
Molina MMP7V 
HidalgoCigna-HealthSpringH7
MolinaH6 
SuperiorH5 
Cigna-HealthSpring MMPH8 
Molina MMPH9 
Superior MMPHA 
JeffersonWellpoint8R
United Healthcare8S 
Molina8T 
LubbockWellpoint5A
Superior5B 
Medicaid Rural Service Area (RSA) Central TexasSuperiorC4
United HealthcareC5 
Medicaid RSA Northeast TexasCigna-HealthSpringN3
United HealthcareN4 
Medicaid RSA West TexasWellpointW5
SuperiorW6 
NuecesUnited Healthcare85
Superior Health Plan86
TarrantWellpoint69
Cigna-HealthSpring6C
Wellpoint MMP6F
Cigna-HealthSpring MMP6G
TravisWellpoint19
United Healthcare18

9120 Enrollment - Initial

Revision 24-2; Effective May 21, 2024

Use the enrollment record in the Service Authorization System Online (SASO) to register the enrollment begin and end date for the STAR+PLUS Home and Community Based Services (HCBS) program applicant.

Program Support Staff (PSU) staff will create an enrollment record for STAR+PLUS HCBS program eligibility for applicants whose individual service plan (ISP) was not transmitted electronically.

PSU staff confirm enrollment registration in SASO, take a screenshot of the enrollment registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

To register an enrollment record for a STAR+PLUS HCBS program applicant whose ISP requires manual entry, PSU staff must:

  1. Select the Enrollment field in the Program and Service functional area.
  2. Select Add and a blank Enrollment Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu.
  5. Move to the Living Arrangement field, and select the appropriate community-based living arrangement from the drop-down menu. The living arrangement must match the information provided in the initial ISP.
  6. Move to the Begin Date field and enter the effective date of the ISP period.
  7. Leave the End Date field blank.
  8. Leave the Termination Code and Waiver Type fields at the defaults.
  9. Select the Save button.

9130 Service Plan - Initial

Revision 24-2; Effective May 21, 2024

Use the Service Plan record in the Service Authorization System Online (SASO) to register an individual service plan (ISP) for a STAR+PLUS Home and Community Based Services (HCBS) program member. The service plan record includes the annual STAR+PLUS HCBS program ISP cost limit based on the member’s Resource Utilization Group (RUG) value and the total estimated cost taken from the member’s Form H1700-1, Individual Service Plan (PDF), on page 1, for members who do not have an electronic ISP.

Program Support Staff (PSU) staff will create a service plan record, if applicable, for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm service plan registration in SASO, take a screenshot of the service plan registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

To register a service plan record for a STAR+PLUS HCBS program applicant whose ISP requires manual entry, PSU staff must:

  1. Select the Service Plan field in the Program and Service functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Ceiling field and enter the annual STAR+PLUS HCBS program ISP cost limit for the RUG value entered on the current ISP coverage period, from Form H1700-1.  For a STAR+PLUS HCBS program member who is ventilator use-dependent, enter the annual STAR+PLUS HCBS program ISP cost limit based on the RUG value and ventilator use of the member (6-23 hours or 24 hours continuous).
  6. Move to the Begin Date field and enter the effective date of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Move to the Amount Authorized field and enter the total estimated cost of all STAR+PLUS HCBS program services authorized for the current ISP coverage period, from Form H1700-1.
  9. Leave the Amount Paid field at the default setting of 0.00.
  10. Leave the Units Authorized field at the default of 0.00.
  11. Leave the Units Paid field at the default of 0.00.
  12. Select the Save button. 

9140 Service Authorization - Initial

Revision 24-2; Effective May 21, 2024

The Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal automatically generates service authorization records in the Service Authorization System Online (SASO) if the individual service plan (ISP) is electronic.

Program Support Unit (PSU) staff:

  • Do not register service authorization records for an electronic individual service plan (ISP).
  • Create a service authorization record, if applicable, for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose ISP was not transmitted electronically.
  • Must confirm service authorization registration in SASO, take a screenshot of the service authorization registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

To register a service authorization record for STAR+PLUS HCBS program eligibility for a member whose ISP requires manual entry, PSU staff must:

  1. Select the Service Authorization field in the Program and Service functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and TermCode fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave the Amount field at the default.
  10. Move to the Begin Date field and enter the effective date of the ISP period.
  11. Move to the End Date field and enter the last day of the ISP period.
  12. Move to the Contract No field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCOService AreaContract Number
MolinaBexar1014430
Molina MMPBexar1026341
MolinaHarris1014431
Molina MMPHarris1026344
MolinaJefferson1019598
MolinaDallas1018980
Molina MMPDallas1026342
MolinaEl Paso1019987
Molina MMPEl Paso1026343
MolinaHidalgo1019988
Molina MMPHidalgo1026345
SuperiorBexar1014433
Superior MMPBexar1026337
SuperiorNueces1014434
SuperiorDallas1018981
Superior MMPDallas1026338
SuperiorHidalgo1019985
Superior MMPHidalgo1026339
SuperiorLubbock1019986
SuperiorMedicaid Rural Service Area (RSA) Central1025731
SuperiorMedicaid RSA West1025730
United HealthcareHarris1014435
United Healthcare MMPHarris1026334
United HealthcareJefferson1019600
United HealthcareMedicaid RSA Central1025732
United HealthcareMedicaid RSA Northeast1025734
United HealthcareNueces1014437
United HealthcareTravis1014438
WellpointBexar1014439
Wellpoint MMPBexar1026326
WellpointHarris1014440
Wellpoint MMPHarris1026331
WellpointJefferson1019599
WellpointTravis1014442
WellpointEl Paso1019979
Wellpoint MMPEl Paso1026328
WellpointLubbock1019983
WellpointMedicaid RSA West1025729
WellpointTarrant1018977
Wellpoint MMPTarrant1026332
Cigna-HealthSpringTarrant1018979
Cigna-HealthSpring MMPTarrant1026333
Cigna-HealthSpringHidalgo1019984
Cigna-HealthSpring MMPHidalgo1026335
Cigna-HealthSpringMedicaid RSA Northeast1025733

9150 Level of Service - Initial

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) registered on a level of service (LOS) record in the Service Authorization System Online (SASO). The LOS record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the RUG value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The LOS record is system generated from the information stored in the SASO database. The system generated LOS record will have an end date that may need to be extended by Program Support Unit (PSU) staff through the last day of the month in which the individual service plan (ISP) expires.

PSU staff will create an LOS record, if applicable, for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

Example: If the MN/LOC Assessment is approved with an effective date of May 13, 2019, the system-generated end date for the LOS record will be May 12, 2020. If the ISP period is June 1, 2019 to May 31, 2020, the LOS record will need to be extended to May 31, 2020, so the member has coverage for the entire ISP period.

To extend an LOS record for a STAR+PLUS HCBS program applicant, PSU staff must:

  1. Select the Level of Service field in the Medical functional area.
  2. Select the Level of Service record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an LOS record has not been created in SASO, PSU staff must complete the following steps to add the record:

  1. Select the Level of Service field in the Medical functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CR – CBA RUG from the drop-down menu.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Level field and enter the RUG level from Form H1700-1, Individual Service Plan (Pg. 1). The RUG level can be verified in the MN/LOC Assessment.
  6. Move to the Begin Date field and enter the first day of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Select the Save button.

9160 Diagnosis - Initial

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a diagnosis registered in the Service Authorization System Online (SASO). The diagnosis record should be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The diagnosis record is system generated from the information stored in the SASO database. The system-generated diagnosis record will have an end date that may need to be extended by Program Support Staff (PSU) staff through the last day of the month in which the individual service plan (ISP) expires.

PSU staff will create a diagnosis record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

Example: If MN is approved with an effective date of November 13, 2019, the system generated end date will be November 30, 2020.

To extend a diagnosis record for a STAR+PLUS HCBS program applicant or member:

  1. Select the Diagnosis field in the Medical functional area.
  2. Select the Diagnosis record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If a diagnosis record has not been created in SASO, PSU staff must complete the following steps to add the record:

  1. Select the Diagnosis field in the Medical functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses from the most recent Waiver 3.0 Form, Section I, in TMHP. The diagnosis can be verified in the MN/LOC Assessment.
  7. Select Version ICD-10-CM CODE.
  8. Select the Save button.

9170 Medical Necessity - Initial

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a medical necessity (MN) registered in the Service Authorization System Online (SASO). The MN record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The MN record is system generated from the information stored in the SASO database. The system-generated MN record will have an end date that may need to be extended by Program Support Staff (PSU) staff through the last day of the month in which the individual service plan (ISP) expires.

PSU staff will create an MN record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

PSU staff must confirm MN registration in SASO, take a screenshot of the MN registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Example: If MN is approved with an effective date of May 13, 2019, the system generated end date will be May 31, 2020.

To extend an MN record for a STAR+PLUS HCBS program applicant, PSU staff must:

  1. Select the MN field in the Medical functional area.
  2. Select the MN record you wish to extend.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an MN record has not been created in SASO, PSU staff must complete the following steps to add the record:

  1. Select the MN field in the Medical functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Move to the MN field and select Y - YES from the drop-down menu.
  4. Move to the Permanent field and select N – NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Save button.

9200, Reassessment Service Authorization

Revision 18-0; Effective September 4, 2018

When Program Support Unit (PSU) staff authorize STAR+PLUS Home and Community Based Services (HCBS) program services for a reassessment of the individual service plan (ISP) in the Service Authorization System Online (SASO), PSU staff must check or create the following records according to Sections 9210 through 9270:

  • Authorizing Agent – Reassessment;
  • Enrollment – Reassessment;
  • Service Plan – Reassessment;
  • Service Authorization – Reassessment;
  • Level of Service  – Reassessment;
  • Diagnosis – Reassessment; and
  • Medical Necessity – Reassessment.

9210 Authorizing Agent – Reassessment

Revision 18-0; Effective September 4, 2018

Check the authorizing agent record for accuracy. If there are no changes, leave the authorizing agent record open-ended. Currently, although the Service Authorization System Online (SASO) will accept multiple authorizing agent records, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal will only accept two authorizing agent records when a SASO file is transmitted to TMHP. Therefore, select “NO” in the ‘Send to TMHP’ field for all updates.

Program Support Unit (PSU) staff will create an authorizing agent record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose individual service plan (ISP) was not transmitted electronically.

9220 Enrollment – Reassessment

Revision 18-0; Effective September 4, 2018

Check the enrollment record for accuracy and to be sure it is open-ended. If it is open-ended, make no changes. If it has an end date, delete the end date or create another record with a new begin date. To ensure that there is not a gap in service, the begin date of the enrollment for the new individual service plan (ISP) year is the day after the end date of the previous ISP year.

Program Support Staff (PSU) staff will create a service plan record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm enrollment registration in SASO, take a screenshot of the enrollment registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

9230 Service Plan – Reassessment

Revision 18-0; Effective September 4, 2018

A new service plan record may need to be created to register the Resource Utilization Group (RUG) cost limit and the amount of services authorized for the new individual service plan (ISP) year.

Because the ISP is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal automatically generates service plan records in the Service Authorization System Online (SASO).

Program Support Unit (PSU) staff do not need to create a service plan record for electronic ISPs.

PSU staff will create a service plan record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm service plan registration in SASO, take a screenshot of the service plan registration, and upload the screenshot to the HHS Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

9240 Service Authorization – Reassessment

Revision 18-0; Effective September 4, 2018

If the managed care organization (MCO) uploads a timely reassessment packet, Program Support Unit (PSU) staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility for the new individual service plan (ISP) year. To ensure there is no gap in service, the begin date of the authorization for the new ISP year is the day after the end date of the previous ISP year.

Because the ISP is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal automatically generates service authorization records in the Service Authorization System Online (SASO).

PSU staff should not need to register service authorization records for electronic ISPs.

PSU staff will create a service authorization record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

PSU staff confirm service authorization registration in SASO, take a screenshot of the service authorization registration in SASO, and upload the screenshot to the HHS Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

If the MCO does not upload a timely reassessment packet, two service authorization records will be required for STAR+PLUS HCBS program eligibility. The first service authorization record for STAR+PLUS HCBS program eligibility will be entered with service group (SG) 19/service code (SC) 13 for the month(s) for which the ISP was late. The second service authorization record for STAR+PLUS HCBS program eligibility will be entered with SG 19/SC 12 for the remaining ISP period.

To enter a service authorization record for an untimely reassessment for STAR+PLUS HCBS program eligibility for an applicant or member whose ISP is not electronic, PSU staff must:

  1. Select the Service Authorization field in the Program and Service functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 13 – NURSING SERVICES from the drop-down menu.
  5. Leave the Fund and TermCode fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 4 – PER AUTHORIZATION from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount field at the default.
  10. Move to the Begin Date field and enter the effective date of the new ISP coverage period.
  11. Create two service authorization records. For the first record, move to the End Date field and enter the last day of the month the ISP was received. Note: For the second record, repeat steps 1 through 10. Move to the Begin Date field and enter the first of the next month and move to the End Date field and enter the end date of the ISP period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCOService AreaContract Number
MolinaBexar1014430
Molina MMPBexar1026341
MolinaHarris1014431
Molina MMPHarris1026344
MolinaJefferson1019598
MolinaDallas1018980
Molina MMPDallas1026342
MolinaEl Paso1019987
Molina MMPEl Paso1026343
MolinaHidalgo1019988
Molina MMPHidalgo1026345
SuperiorBexar1014433
Superior MMPBexar1026337
SuperiorNueces1014434
SuperiorDallas1018981
Superior MMPDallas1026338
SuperiorHidalgo1019985
Superior MMPHidalgo1026339
SuperiorLubbock1019986
SuperiorMedicaid Rural Service Area (RSA) Central1025731
SuperiorMedicaid RSA West1025730
United HealthcareHarris1014435
United Healthcare MMPHarris1026334
United HealthcareJefferson1019600
United HealthcareMedicaid RSA Central1025732
United HealthcareMedicaid RSA Northeast1025734
United HealthcareNueces1014437
United HealthcareTravis1014438
AmerigroupBexar1014439
Amerigroup MMPBexar1026326
AmerigroupHarris1014440
Amerigroup MMPHarris1026331
AmerigroupJefferson1019599
AmerigroupTravis1014442
AmerigroupEl Paso1019979
Amerigroup MMPEl Paso1026328
AmerigroupLubbock1019983
AmerigroupMedicaid RSA West1025729
AmerigroupTarrant1018977
Amerigroup MMPTarrant1026332
Cigna-HealthSpringTarrant1018979
Cigna-HealthSpring MMPTarrant1026333
Cigna-HealthSpringHidalgo1019984
Cigna-HealthSpring MMPHidalgo1026335
Cigna-HealthSpringMedicaid RSA Northeast1025733
  1. The NPI field is read-only.
  2. Select the Save button.

9250 Level of Service – Reassessment

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a Resource Utilization Group (RUG) value registered in the Service Authorization System Online (SASO). The level of service (LOS) record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the RUG value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The LOS record is system generated from the information stored in the SASO database. The system-generated LOS record will have a begin and end date that matches the new individual service plan (ISP) year.

Program Support Unit (PSU) staff will create an LOS record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

Example: A member with an initial ISP coverage period of December 1, 2019 through November 30, 2020, is authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective December 1, 2019 through November 30, 2020. These new begin and end dates will be system generated in the LOS record.

9260 Diagnosis – Reassessment

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a diagnosis registered in the Service Authorization System Online (SASO). The diagnosis record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information from this form to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is commuted, TMHP submits the decision to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The diagnosis record is system generated from the information stored in the SASO database. The system-generated diagnosis record will have a begin and end date that matches the new individual service plan (ISP) year.

Program Support Unit (PSU) staff will create a diagnosis record for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

Example: A member with an initial ISP coverage period of November 1, 2019 through October 31, 2020, is re-authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective November 1, 2019 through October 31, 2020. These new begin and end dates will be system generated in the diagnosis record.

9270 Medical Necessity – Reassessment

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a medical necessity (MN) registered in the Service Authorization System Online (SASO). The MN record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment for the annual reassessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The MN record is system generated from the information stored in the SASO database. The system-generated MN record will have a begin date and an end date that matches the new individual service plan (ISP) year.

Program Support Unit (PSU) staff will create an MN record(s) for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

PSU staff must confirm MN registration in SASO, take a screenshot of the MN registration, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Example: A member with an initial ISP coverage period of February 1, 2019 through Jan. 31, 2020, is authorized for STAR+PLUS HCBS program eligibility. The new ISP year will be effective February 1, 2019 through January 31, 2020. These new begin and end dates will be system generated in the MN record. The MN record must be forced in SASO to register an MN determination for a reassessment when the MN is approved in the TMHP LTC Online Portal but will not convert to SASO because of a mismatch of member information between the MN/LOC Assessment and the Texas Integrated Eligibility Redesign System (TIERS).

9300, Transfers

Revision 18-0; Effective September 4, 2018

There are several situations that are considered transfers for STAR+PLUS Home and Community Based Service (HCBS) program members, and the procedures differ for each.

9310 Transfers from One STAR+PLUS Area to Another Area

Revision 23-2; Effective May 15, 2023

Two different situations can occur when a STAR+PLUS Home and Community Based Services (HCBS) program member transfers from one service area (SA) to another SA. The first situation is when a member transfers to a new SA that the current managed care organization (MCO) also operates in, and the member wants to stay with that MCO. The contract number will change even though the member stays with the same MCO. As a result, the member’s records will need to be closed under the previous contract number and opened under the new contract number. The second situation is when the member transfers to a new SA that the current MCO does not operate in, and the member changes MCOs.

The Texas Integrated Eligibility Redesign System (TIERS) updates the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) if the member's individual service plan (ISP) is electronic and the member made a new MCO selection. The TMHP LTCOP automatically interfaces with the Service Authorization System Online (SASO) to: 

  • close the SASO registration records for the losing MCO; and 
  • create new SASO registration records for the gaining MCO.

Program Support Unit (PSU) staff must manually close SASO registration records when a member’s MCO plan change is not timely. To process the transfer, the gaining PSU staff must:

  • close the existing: 
    • Authorizing Agent (service code (SC) 12) record; 
    • Service Authorization (service group (SG) 19/service code (SC) 12) record; 
  • open a new: 
    • Authorizing Agent (SC 12) record; and 
    • Service Authorization (SG 19/SC 12) record using the MCO contract number in the new SA.

The gaining PSU staff must complete the following activities to close the Authorizing Agent record:

  1. Open the STAR+PLUS HCBS program member’s case in the SASO.
  2. Select the Authorizing Agent field from the Case Worker functional area.
  3. Select the Authorizing Agent record you wish to close.
  4. Select the Modify button to open and modify.
  5. Move to the End Date field and enter the effective date of the termination, which is the last day of the month in which the member moved to the new SA.
  6. Select the Save button.

The gaining PSU staff must complete the following activities to close the Service Authorization record:

  1. Select the Service Authorization field in the Program and Service functional area.
  2. Select the appropriate Service Authorization (SC 12) record you wish to close.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and enter the effective date of the termination. This will be the last day of the month in which the member moved to the new SA.
  5. Move to the Termination Code field and select “23 - Transferred to another service” (or the appropriate code) from the drop-down menu.
  6. Select the Save button.
  7. Select Submit to SASO.
  8. Select Outbox and then Inbox to ensure the case processed accurately.

The Service Authorization record is opened per procedures outlined in determining initial eligibility for STAR+PLUS HCBS program members with the following exceptions:

  • The begin date for these records is the first day of the month following the month the member moved to the new SA.
  • The end date for the Service Authorization (SC 12) record is the same as the current ISP period.

Example: If a STAR+PLUS HCBS program member with an ISP period of Nov. 1, 2019, to Oct. 31, 2020, transfers to another STAR+PLUS SA on Jan. 15, 2020, the end date for these records remains Oct. 31, 2018.

9320 Transfers from One MCO to Another MCO in the Same Service Area

Revision 18-0; Effective September 4, 2018

If the member's individual service plan (ISP) is electronic and the member made a new managed care organization (MCO) selection timely, the Texas Integrated Eligibility Redesign System (TIERS) updates the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, which automatically closes the registration for the losing MCO and creates the registration for the gaining MCO in the Service Authorization System Online (SASO). If the member's plan change is not timely, Program Support Unit (PSU) staff follow existing policy, stated below.

PSU staff process the request by closing the existing service authorization record (service code (SC) 12) for the losing MCO and creating a new service authorization record (SC 12) for the gaining MCO.

To close the existing service authorization records, PSU staff must:

  1. Move to the Service Authorization field in the Program and Service functional area.
  2. Select the appropriate Service Authorization record you wish to close.
  3. Select the Modify button.
  4. Move to the End Date field and enter the effective date of the termination, which is the last day of the month in which the member was enrolled in the losing MCO.
  5. Move to the Termination Code field and select “39 – Other” (or the appropriate code) from the drop-down menu.
  6. Select the Save button.
  7. Select Submit to SASO.
  8. Select Outbox and then Inbox to ensure the case processed accurately.

To create a new service authorization record for the new MCO, PSU staff must:

  1. Select the Service Authorization field in the Program and Service functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and TermCode fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop-down menu.
  8. Move to the Units field and enter 1.00.
  9. Leave the Amount field at the default.
  10. Move to the Begin Date field and enter the new MCO contract number or plan code enrollment date.
  11. Move to the End Date field; the end date for the service authorization record is the last day of the ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCOService AreaContract Number
MolinaBexar1014430
Molina MMPBexar1026341
MolinaHarris1014431
Molina MMPHarris1026344
MolinaJefferson1019598
MolinaDallas1018980
Molina MMPDallas1026342
MolinaEl Paso1019987
Molina MMPEl Paso1026343
MolinaHidalgo1019988
Molina MMPHidalgo1026345
SuperiorBexar1014433
Superior MMPBexar1026337
SuperiorNueces1014434
SuperiorDallas1018981
Superior MMPDallas1026338
SuperiorHidalgo1019985
Superior MMPHidalgo1026339
SuperiorLubbock1019986
SuperiorMedicaid Rural Service Area (RSA) Central1025731
SuperiorMedicaid RSA West1025730
United HealthcareHarris1014435
United Healthcare MMPHarris1026334
United HealthcareJefferson1019600
United HealthcareMedicaid RSA Central1025732
United HealthcareMedicaid RSA Northeast1025734
United HealthcareNueces1014437
United HealthcareTravis1014438
AmerigroupBexar1014439
Amerigroup MMPBexar1026326
AmerigroupHarris1014440
Amerigroup MMPHarris1026331
AmerigroupJefferson1019599
AmerigroupTravis1014442
AmerigroupEl Paso1019979
Amerigroup MMPEl Paso1026328
AmerigroupLubbock1019983
AmerigroupMedicaid RSA West1025729
AmerigroupTarrant1018977
Amerigroup MMPTarrant1026332
Cigna-HealthSpringTarrant1018979
Cigna-HealthSpring MMPTarrant1026333
Cigna-HealthSpringHidalgo1019984
Cigna-HealthSpring MMPHidalgo1026335
Cigna-HealthSpringMedicaid RSA Northeast1025733
  1. The NPI field is read-only.
  2. Select the Save button.
  3. Select Submit to SASO.
  4. Select Outbox and then Inbox to ensure the case processed accurately.

9400, MFP Authorization for STAR+PLUS HCBS Program Applicant

Revision 18-0; Effective September 4, 2018

After Program Support Unit (PSU) staff verify that the applicant left the nursing facility (NF), PSU staff complete the following steps listed below. PSU staff do not close the Authorizing Agent, Medical Necessity, Level of Service Resource Utilization Group (RUG) records. PSU staff must also ensure Provider Claims Services (PCS) closes the enrollment and service authorization records for service codes (SC) 1, 3, 50 and 60.

For individuals who are not enrolled in STAR+PLUS until they begin receiving the STAR+PLUS Home and Community Based Services (HCBS) program, create a one-day service authorization record for the first day of the month in which a Money Follows the Person (MFP) individual is discharged from an NF, unless the individual discharges on the first day of a month.

Example: An individual who is not enrolled in STAR+PLUS leaves the NF and begins the STAR+PLUS HCBS program on December 25, 2019. PSU staff register the initial individual service plan (ISP) in the Service Authorization System Online (SASO) with an effective date of December 25, 2019 through December 31, 2020. In addition to registering the initial ISP, PSU staff create all the records listed below with a begin date of December 1, 2019, and an end date of December 1, 2019.

PSU staff must check or create the one-day service authorization for the following records for service group (SG) 19 according to Sections 9410 through 9470:

  • Authorizing Agent for MFP Applicant (if needed);
  • Enrollment for MFP Applicant;
  • Service Plan for MFP Applicant;
  • Service Authorization for MFP Applicant;
  • Level of Service for MFP Applicant;
  • Diagnosis for MFP Applicant; and
  • Medical Necessity for MFP Applicant.

A one-day overlap of the records listed is allowed.

Note: Individuals released from an NF and authorized for the STAR+PLUS HCBS program should be enrolled under MFP. In the Enrollment record, select "12 – MONEY FOLLOWS THE PERSON” from the drop-down menu in the Enrolled From field. Do not use “Enrolled from nursing facility” to designate MFP members.

To authorize STAR+PLUS HCBS program eligibility for an MFP applicant:

After creating the one-day records above, when applicable, PSU must create the records needed for the ongoing MFP STAR+PLUS HCBS program eligibility. These records must be completed to check or create an initial service authorization for the STAR+PLUS HCBS program according to Sections 9410 through 9470 listed above.

9410 Authorizing Agent for MFP Applicant

Revision 24-2; Effective May 21, 2024

There will be one authorizing agent registered for a Money Follows the Person (MFP) applicant.

Program Support Unit (PSU) staff are registered as the authorizing agent when the initial authorization is authorized.

To register an authorizing agent for an MFP applicant, PSU staff must:

  1. Select the Authorizing Agent field in the Case Worker functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Type field and select CM - CASE MANAGER from the drop-down menu.
  4. Move to the Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Leave the Send to TMHP field at the default selection N - NO.
  6. Move to the Begin Date field and enter the effective date of the ISP period.
  7. Leave the End Date field blank.
  8. Move to the Authorizing Agent ID field and enter STAR+PLUS.
  9. Leave the Agency field at the default selection 324 - DHS.
  10. Move to the Name field and enter the PSU or ERS staff’s name.
  11. Move to the Phone field and enter the phone number of the authorizing agent. Enter the area code, phone number and extension.
  12. Move to the Mail Code field and enter the appropriate Managed Care Organization (MCO) Plan Code. Note: Six service areas include Medicare-Medicaid Plans (MMP).
Service AreaMCO Plan NameMCO Plan Code
BexarWellpoint45
Molina46 
Superior47 
Wellpoint MMP4F 
Molina MMP4G 
Superior MMP4H 
DallasMolina9F
Superior Health Plan9H 
Molina MMP9J 
Superior MMP9K 
El PasoMolina33
Wellpoint34 
Molina MMP3G 
Wellpoint MMP3H 
HarrisWellpoint7P
United Healthcare7R 
Molina7S 
Wellpoint MMP7Z 
United Healthcare MMP7Q 
Molina MMP7V 
HidalgoCigna-HealthSpringH7
MolinaH6
SuperiorH5
Cigna-HealthSpring MMPH8
Molina MMPH9
Superior MMPHA
JeffersonWellpoint8R
United Healthcare8S
Molina8T
LubbockWellpoint5A
Superior5B
Medicaid Rural Service Area (RSA) Central TexasSuperiorC4
United HealthcareC5
Medicaid RSA Northeast TexasCigna-HealthSpringN3
United HealthcareN4
Medicaid RSA West TexasWellpointW5
SuperiorW6
NuecesUnited Healthcare85
Superior Health Plan86
Tarrant 
 
Wellpoint69
Cigna-HealthSpring6C
Wellpoint MMP6F
Cigna-HealthSpring MMP6G
TravisWellpoint19
United Healthcare18
  1. Select the Save button.

9420 Enrollment for MFP Applicant

Revision 24-2; Effective May 21, 2024

Use the Enrollment record in the Service Authorization System Online (SASO) to register the enrollment begin date with an open-ended date for the STAR+PLUS Home and Community Based Services (HCBS) program member.

Program Support Staff (PSU) staff:

  • Create an enrollment record for STAR+PLUS HCBS program eligibility for members.
  • Take a screenshot of the enrollment registration in SASO, and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART).

To register an authorizing agent for a Money Follows the Person (MFP) applicant, PSU staff must:

  1. Select the Enrollment field in the Program and Service functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Enrolled From field and select the appropriate entry from the drop-down menu. If this is an MFP authorization, be sure to select 12 - MONEY FOLLOWS THE PERSON from the drop-down menu.
  5. Move to the Living Arrangement field and select the appropriate community-based living arrangement from the drop-down menu.
  6. Move to the Begin Date field and enter the effective date of the ISP period.
  7.  Leave the End Date field blank.
  8. Leave the Termination Code and Waiver Type at the defaults.
  9. Select the Save button.

9430 Service Plan for MFP Applicant

Revision 18-0; Effective September 4, 2018

The service plan record is used to register an individual service plan (ISP) for a STAR+PLUS Home and Community Based Services (HCBS) program member. The record includes the annual STAR+PLUS HCBS program ISP cost limit based on the member’s Resource Utilization Group (RUG) value and the total estimated cost of the STAR+PLUS HCBS program services taken from the member’s Form H1700-1, Individual Service Plan (Pg. 1).

Program Support Staff (PSU) staff will create a service plan record for STAR+PLUS HCBS program eligibility for members.

PSU staff will take a screenshot of the service plan registration in the Service Authorization System Online (SASO) and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

To register a service plan for a Money Follows the Person (MFP) applicant, PSU staff must:

  1. Select the Service Plan field in the Program and Service functional area.
  2. Select Add and a blank Service Plan Details record will appear.
  3. Leave the Type field at the default selection AN - ANNUAL PLAN.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Ceiling field and enter the annual STAR+PLUS HCBS program ISP cost limit for the RUG value entered on the Level of Service record. For a STAR+PLUS HCBS program member who uses a ventilator, enter the annual STAR+PLUS HCBS program ISP cost limit based on the RUG value and ventilator use of the member (6-23 hours or 24 hours continuous).

Move to the Begin Date field and enter the effective date of the ISP coverage period.

  1. Move to the End Date field and enter the last day of the ISP coverage period.
  2. Move to the Amount Authorized field and enter the total estimated cost of all  STAR+PLUS HCBS program services authorized for the current ISP coverage period from Form H1700-1.
  3. Leave the Amount Paid field at the default setting of 0.00.
  4. Leave the Units Authorized field at the default of 0.00.
  5. Leave the Units Paid field at the default of 0.00.
  6. Select the Save button.

9440 Service Authorization for MFP Applicant

Revision 18-0; Effective September 4, 2018

Program Support Unit (PSU) staff create one service authorization record for STAR+PLUS Home and Community Based Services (HCBS) program eligibility.

PSU staff will create a service authorization record for STAR+PLUS HCBS program eligibility for members.

PSU staff will take a screenshot of the service authorization registration in the Service Authorization System Online (SASO) and upload the screenshot to the HHS Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

To register a service authorization record for a Money Follows the Person (MFP) applicant, PSU staff must:

  1. Select the Service Authorization field in the Program and Service functional area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down list.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Leave the Fund and TermCode fields at the defaults.
  6. Leave the Agency field at the default selection 324 - DHS.
  7. Move to the Unit Type field and select 2 – MONTH from the drop down list.
  8. Move to the Units field and enter 1.00.
  9. Leave Amount at the default.
  10. Move to the Begin Date field and enter the effective date of the ISP coverage period.
  11. Move to the End Date field and enter the last day of the ISP coverage period.
  12. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCOService AreaContract Number
MolinaBexar1014430
Molina MMPBexar1026341
MolinaHarris1014431
Molina MMPHarris1026344
MolinaJefferson1019598
MolinaDallas1018980
Molina MMPDallas1026342
MolinaEl Paso1019987
Molina MMPEl Paso1026343
MolinaHidalgo1019988
Molina MMPHidalgo1026345
SuperiorBexar1014433
Superior MMPBexar1026337
SuperiorNueces1014434
SuperiorDallas1018981
Superior MMPDallas1026338
SuperiorHidalgo1019985
Superior MMPHidalgo1026339
SuperiorLubbock1019986
SuperiorMedicaid Rural Service Area (RSA) Central1025731
SuperiorMedicaid RSA West1025730
United HealthcareHarris1014435
United Healthcare MMPHarris1026334
United HealthcareJefferson1019600
United HealthcareMedicaid RSA Central1025732
United HealthcareMedicaid RSA Northeast1025734
United HealthcareNueces1014437
United HealthcareTravis1014438
AmerigroupBexar1014439
Amerigroup MMPBexar1026326
AmerigroupHarris1014440
Amerigroup MMPHarris1026331
AmerigroupJefferson1019599
AmerigroupTravis1014442
AmerigroupEl Paso1019979
Amerigroup MMPEl Paso1026328
AmerigroupLubbock1019983
AmerigroupMedicaid RSA West1025729
AmerigroupTarrant1018977
Amerigroup MMPTarrant1026332
Cigna-HealthSpringTarrant1018979
Cigna-HealthSpring MMPTarrant1026333
Cigna-HealthSpringHidalgo1019984
Cigna-HealthSpring MMPHidalgo1026335
Cigna-HealthSpringMedicaid RSA Northeast1025733
  1. The NPI field is read-only.
  2. Select the Save button.

9450 Level of Service for MFP Applicant

Revision 18-0; Effective September 4, 2018

There will be an existing service group (SG) 1 (NF) level of service (LOS) record. However, Program Support Unit (PSU) staff will be required to create a new LOS record for SG 19 STAR+PLUS Home and Community Based Services (HCBS) program. The SG 1 (NF) LOS record can remain open.

All STAR+PLUS HCBS program members must have an LOS registered in the Service Authorization System Online (SASO). The LOS record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

PSU staff will create an LOS record, if applicable, for STAR+PLUS HCBS program eligibility for members.

To add an LOS record, PSU staff must complete the following steps:

  1. Select the Level of Service field in the Medical functional area.
  2. Select Add and a blank Level of Service Details record will appear.
  3. Move to the Type field and select CR – CBA RUG from the drop-down menu.
  4. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  5. Move to the Level field and enter the RUG.
  6. Move to the Begin Date field and enter the first day of the ISP period.
  7. Move to the End Date field and enter the last day of the ISP period.
  8. Select the Save button.

9460 Diagnosis for MFP Applicant

Revision 18-0; Effective September 4, 2018

There will be an existing service group (SG) 1 diagnosis record. Program Support Unit (PSU) staff must create a new diagnosis record for SG 19 STAR+PLUS Home and Community Based Services (HCBS) program.

All STAR+PLUS HCBS program members must have a diagnosis registered in the Service Authorization System Online (SASO). The diagnosis record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The system-generated diagnosis record will have an end date that may need to be extended by PSU staff through the last day of the month in which the individual service plan (ISP) expires, if applicable.

To add an SG 19 diagnosis record in the SASO, PSU staff must complete the following steps:

  1. Select the Diagnosis field in the Medical functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses.
  7. Leave Version field at the default.
  8. Select the Save button.

9470 Medical Necessity for MFP Applicant

Revision 18-0; Effective September 4, 2018

All STAR+PLUS Home and Community Based Services (HCBS) program members must have a medical necessity (MN) registered in the Service Authorization System Online (SASO). The MN record will be system generated from information received from the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. The managed care organization (MCO) nurse completes the Medical Necessity and Level of Care (MN/LOC) Assessment and submits the information to the TMHP LTC Online Portal or uses the nursing facility (NF) minimum data set (MDS). After TMHP determines MN and the Resource Utilization Group (RUG) value is computed, TMHP submits the decision back to the Texas Health and Human Services Commission (HHSC) where the MN/LOC Assessment is stored in the SASO database.

The MN record is system generated from the information stored in the SASO database. The system-generated MN record will have an end date that may need to be extended by Program Support Unit (PSU) staff through the last day of the month in which the individual service plan (ISP) expires.

PSU staff will create an MN record for STAR+PLUS HCBS program eligibility for members.

PSU staff will take a screenshot of the MN registration in SASO and upload the screenshot to the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART), following the instructions in Appendix XXXIII, STAR+PLUS HEART Naming Conventions.

Example: If MN is approved with an effective date of May 13, 2019, the system-generated end date will be May 31, 2020. Note: An open-ended MN record must be terminated with the end-date of the ISP.

PSU staff can create MN record(s) for STAR+PLUS HCBS program eligibility for members whose ISP was not transmitted electronically.

To extend an MN record for an MFP applicant, PSU staff must:

  1. Select the MN field in the Medical functional area.
  2. Select the existing MN record.
  3. Select the Modify button to open and modify.
  4. Move to the End Date field and change the date to the last day of the ISP period.
  5. Select the Save button.

If an MN record has not been created in SASO, PSU staff complete the following steps to add the record:

  1. Select the MN field in the Medical functional area.
  2. Select Add and a blank MN Details record will appear.
  3. Leave the MN field at the default of Y - YES.
  4. Leave the Permanent field at the default of N - NO.
  5. Move to the Begin Date field and enter the first day of the ISP period.
  6. Move to the End Date field and enter the last day of the ISP period.
  7. Select the Save button.

To add a service group (SG) 19 diagnosis record in the SASO, PSU staff must complete the following steps:

  1. Select the Diagnosis field in the Medical functional area.
  2. Select Add and a blank Diagnosis Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down menu.
  4. Move to the Begin Date field and enter the first day of the ISP period.
  5. Move to the End Date field and enter the last day of the ISP period.
  6. Enter up to five diagnoses.
  7. Leave Version field at the default.
  8. Select the Save button.

9480 MFPD for STAR+PLUS HCBS Program Applicant

Revision Notice 24-2; Effective May 21, 2024

The option to electronically submit an individual service plan (ISP) for a nursing facility (NF) resident is not available. The managed care organizations (MCO) must not use the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) Money Follows the Person Demonstration (MFPD) check box. Program Support Unit (PSU) staff must continue to manually register this fund code in the Service Authorization System Online (SASO).

PSU staff must follow the instructions for a Money Follows the Person (MFP) applicant above, with the Service Authorization record completed as follows.

  1. Select the Service Authorization field in the Program and Service functional Area.
  2. Select Add and a blank Service Authorization Details record will appear.
  3. Move to the Service Group field and select 19 - STAR+PLUS from the drop-down list.
  4. Move to the Service Code field and select 12 – CASE MANAGEMENT from the drop-down menu.
  5. Move to the Fund field and select 19MFP – MONEY FOLLOWS PERSON.
  6. Leave the Term. Code field at the defaults.
  7. Leave the Agency field at the default selection 324 - DHS.
  8. Move to the Unit Type field and select 2 – MONTH from the drop-down list.
  9. Move to the Units field and enter 1.00.
  10. Leave the Amount field at the default.
  11. Move to the Begin Date field and enter the effective date of the ISP period.
  12. Move to the End Date field and enter the last day of the ISP period.
  13. Move to the Contract No. field and enter the appropriate contract number of the MCO. Use the following chart to determine the correct contract number. Note: Six service areas include Medicare-Medicaid Plans (MMP).
MCOService AreaContract Number
MolinaBexar1014430
Molina MMPBexar1026341
MolinaHarris1014431
Molina MMPHarris1026344
MolinaJefferson1019598
MolinaDallas1018980
Molina MMPDallas1026342
MolinaEl Paso1019987
Molina MMPEl Paso1026343
MolinaHidalgo1019988
Molina MMPHidalgo1026345
SuperiorBexar1014433
Superior MMPBexar1026337
SuperiorNueces1014434
SuperiorDallas1018981
Superior MMPDallas1026338
SuperiorHidalgo1019985
Superior MMPHidalgo1026339
SuperiorLubbock1019986
SuperiorMedicaid Rural Service Area (RSA) Central1025731
SuperiorMedicaid RSA West1025730
United HealthcareHarris1014435
United Healthcare MMPHarris1026334
United HealthcareJefferson1019600
United HealthcareMedicaid RSA Central1025732
United HealthcareMedicaid RSA Northeast1025734
United HealthcareNueces1014437
United HealthcareTravis1014438
WellpointBexar1014439
Wellpoint MMPBexar1026326
WellpointHarris1014440
Wellpoint MMPHarris1026331
WellpointJefferson1019599
WellpointTravis1014442
WellpointEl Paso1019979
Wellpoint MMPEl Paso1026328
WellpointLubbock1019983
WellpointMedicaid RSA West1025729
WellpointTarrant1018977
Wellpoint MMPTarrant1026332
Cigna-HealthSpringTarrant1018979
Cigna-HealthSpring MMPTarrant1026333
Cigna-HealthSpringHidalgo1019984
Cigna-HealthSpring MMPHidalgo1026335
Cigna-HealthSpringMedicaid RSA Northeast1025733
  1. The NPI field is read-only.
  2. Select the Save button.

Note: The MCO must notify PSU staff once the 365-day MFPD period has passed using Form H2067-MC, Managed Care Programs Communication (PDF). PSU staff must change the Service Authorization record to the default within five business days of the MCO notification.

9500, Mutually Exclusive Services within the STAR+PLUS HCBS Program

Revision 18-0; Effective September 4, 2018

To close services that are mutually exclusive, the Community Care Services Eligibility (CCSE) case manager must close the community services authorization with an effective date one day prior to the date the member is eligible for the STAR+PLUS Home and Community Based Services (HCBS) program.

Example: If an individual receiving Family Care (FC), Emergency Response Services (ERS) and Home-Delivered Meals (HDM) becomes eligible for the STAR+PLUS HCBS program on December 1, 2019, the member will begin receiving his or her services through his managed care organization (MCO) on that date. Therefore, the losing CCSE case manager must close the FC, ERS and HDM services with an effective date of November 30, 2019.

9600, MDCP/CCCP Transitioning to STAR+PLUS HCBS Program

Revision 18-0; Effective September 4, 2018

For Medically Dependent Children Program (MDCP)/Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) members who are transitioning to the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff will enter the initial STAR+PLUS HCBS program eligibility into the Service Authorization System Online (SASO) using the steps for initial eligibility with one exception. The effective begin date for all records will be the first of the month following the member’s 21st birthday.

It is possible the medical records (Medical Necessity, Level of Care or Diagnosis) will have to be extended in SASO to cover the entire individual service plan (ISP) period.

9700, Terminations

Revision 18-0; Effective September 4, 2018

Program Support Unit staff will manually close all service group (SG) 19 records in the Service Authorization System Online (SASO) when all services for an existing STAR+PLUS Home and Community Based Services (HCBS) program member are terminated.

9800, Appeal Extensions for Continued Benefits

Revision 18-0; Effective September 4, 2018

If a STAR+PLUS Home and Community Based Services (HCBS) program member files an appeal and requests continued benefits, Program Support Unit (PSU) staff will extend all records (includes Service Authorization, Service Plan, and Enrollment) by four months. To accomplish this, open each record and modify the record. Change the end date to the last day of the month – four months in the future. This is completed each time an extension is needed.

Multiple extensions may be requested if the appeal process has not been finalized.

Continuation of STAR+PLUS HCBS program benefits during a state fair hearing does not apply for Supplemental Security Income denials. Refer to Section 4222.1, Continuation of STAR+PLUS HCBS Program During a State Fair Hearing, for additional information.

Appendix I-A, Unusual End Dates Report

Revision 19-7; Effective June 3, 2019

 

The Unusual End Dates report lists individual service plans (ISPs) with questionable end dates.

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last medical necessity (MN) registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

  • "Y" means the MN was approved.
  • "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

 

Program Support Unit (PSU) Entry Fields

Comments – PSU staff must enter appropriate comments after researching the ISP end dates. For example, an ISP with:

  • an end date of Oct. 30, 2018, is questionable because there are 31 days in October.
  • an end date of Nov. 1, 2018, is questionable because ISPs end on the last day of the month.
  • a begin date of Jan. 1, 2018, and an end date of Dec. 31, 2018, is questionable because ISPs are not open-ended, nor do they end prior to the begin date.

Unusual End Dates is a periodic report sent on an as-needed basis. The PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-B, Individual Service Plan Expiring Report

Revision 19-7; Effective June 3, 2019

 

The Individual Service Plan (ISP) Expiring report is a check and balance method for the ISP expiring at the end of the report month.

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last medical necessity (MN) registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

  • "Y" means the MN was approved.
  • "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

 

Program Support Unit (PSU) Entry Fields

Date 2065D Sent – Enter the date PSU staff uploaded Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral if the:

  • MN column has "N" (denied);
  • PSU research shows the MN is denied;
  • Managed care organization notifies PSU staff of the MN denial;
  • PSU staff learn of the MN denial by any other method;
  • PSU staff learn of no unmet need at the annual reassessment for the new ISP;
  • PSU staff learn of loss of eligibility; or
  • PSU staff learn of any other denial reasons.

If the MN column has "Y" (approved), leave the field blank.

Date MN Registered in SAS - The date the MN is registered in SASO.

Date ISP Registered – Enter the date PSU staff registered the ISP in SASO, if uploaded to TxMedCentral or Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

Date ISP Posted – The date Form H1700-1, Individual Service Plan (Pg. 1), was uploaded by the MCO to TxMedCentral or TMHP LTC Online Portal.

Comments – PSU staff may enter appropriate comments.

Note: Enter information in the “Comments” field in situations where Form H2065-D is completed but the “Date ISP Registered” is not filled out. The reason entered must provide sufficient detail to ensure clarity.

For expired ISP, Date MCO Contacted – Enter the date the MCO was contacted if the ISP has expired.

Date MCO Contacted, 2nd attempt – Enter the 2nd attempt date the MCO was contacted if the ISP has expired.

Date MCO Contacted, 3rd attempt – Enter the 3rd attempt date the MCO was contacted if the ISP has expired.

The ISP Expiring Report is a monthly report. PSU staff are required to research, resolve and respond within 14 days of receipt.

 

Scan Call for ISP Expiring Report process:

  • PSU staff provide the ISP Expiring Report five business days prior to the scheduled scan call.
  • The MCOs research and provide a written status for each member whose ISP expires within 45 days, indicating the status of the member’s reassessment. The MCO must return a completed report to PSU staff two business days prior to the scan call.
  • PSU staff review the MCO's responses to determine if the MCO needs to provide clarification regarding any member's ISP status. During the scan call, only the ISP status about which PSU staff have questions are reviewed. There will no longer be a need to review each member for the status of the ISP if the MCO's response is sufficient.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-C, Mismatched ISP and MN End Dates Report

Revision 19-7; Effective June 3, 2019
 

The Mismatched Individual Service Plan (ISP) and Medical Necessity (MN) End Dates report shows ISP end dates with MN end dates that do not match.

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

SG – The Service Authorization System Online (SASO) Service Group (SG). The STAR+PLUS SG is 19.

SC – The SASO Service Code (SC). The STAR+PLUS SC is 12. SC 13 should not appear on this report; if SC 13 does appear, disregard the line item.

ISP Begin Date – The begin date of the last ISP registered in SASO.

ISP End Date – The end date of the last ISP registered in SASO.

MN Begin Date – The begin date of the last MN registered in SASO.

MN End Date – The end date of the last MN registered in SASO.

MN – The approval or denial of the MN referenced in the MN begin/end date:

  • "Y" means the MN was approved.
  • "N" means the MN was denied.

RG – The three-digit Risk Group number.

Enroll Month – The most current enrollment month at the time of the report.

Plan – The two-digit managed care organization (MCO) plan code.

TP – The member’s two-digit Medicaid Type Program.

 

Program Support Unit (PSU) Entry Fields

Comments (Date and Action taken) – PSU staff must enter appropriate comments after researching the ISP/MN end dates, which should match. For example, an ISP ends on May 31, 2019, and the MN ends on April 30, 2019. PSU staff must research the reason for the mismatch.

There may be valid situations in which the two dates will not match. For example, a Money Follows the Person (MFP) case has an ISP registered for one day. The MN will not match the one-day registration in this case.

Mismatched ISP and MN End Dates is a periodic report sent on an as-needed basis. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-E, Monthly Plan Changes Report

Revision 19-7; Effective June 3, 2019

 

The Monthly Plan Changes report gives Program Support Unit (PSU) staff a list of members who have changed managed care organization (MCO) plans. PSU staff must correct the contract number in the Service Authorization System Online (SASO) to reflect all MCO plan changes.

 

Report Fields

PCN – The member's nine-digit Medicaid number.

Name – The member's last name, first name and middle initial (when provided).

Current Plan – The two-digit MCO plan code in which the member is currently enrolled.

TP – The member's two-digit Medicaid Type Program.

Prior Plan – The two-digit MCO plan code in which the member was formerly enrolled.

RG – The three-digit Risk Group number.

ISP Begin Date – Enter the begin date of the MCO plan change.

ISP End Date – Enter the end date of the MCO plan change.

 

PSU Entry Fields

Date Completed – PSU staff enter the date SASO corrections were completed.

Comments – Enter any comments relevant to the actions taken.

Monthly Plan Changes is a monthly report. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt.

Note: SASO files used by Program Enrollment Support (PES) staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix I-F, Loss of Eligibility Report

Revision 19-7; Effective June 3, 2019

 

The STAR+PLUS Loss of Eligibility Report provides to Program Support Unit (PSU) staff a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have lost Medicaid eligibility. PSU staff must conduct coordination activities to either reestablish eligibility or close the authorization(s) in the Service Authorization System Online (SASO).

 

Report Fields

PCN — The member’s nine-digit Medicaid number.

Name — The member’s last name, first name and middle initial (when provided).

RG — The three-digit Risk Group number.

Plan Code — The two-digit managed care organization (MCO) plan code in which the member is currently enrolled.

TP — The member’s two-digit Medicaid Type Program (TP).

 

PSU Entry Field

Eligibility Re-established? — PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to determine if Medicaid eligibility has been reestablished. If it has, enter "Yes;" if not, enter "No."

If yes, is manual managed care enrollment needed? — If the response to the previous column was "Yes," PSU staff must check TIERS to determine if Medicaid eligibility and managed care enrollment have been established. If manual managed care enrollment is needed, send an email to the Program Enrollment Support (PES) mailbox.

If no, provide the date Form H2065-D was sent. — PSU staff enter the date Form H2065-D, Notification of Managed Care Program Services, was sent.

Was the decision appealed? — PSU staff enter "Yes" or "No." (No further action is necessary if the response to this question is "no.") If "Yes," continue to the next section.

If yes, was eligibility re-established? — PSU staff check TIERS to determine if Medicaid eligibility has been re-established. If it has, enter "Yes;" if not, enter "No." (No further action is necessary if the response to this question is "No.")

If eligibility was re-established, is manual managed care enrollment needed? — If the response to the previous column was "Yes," PSU staff must check TIERS to determine if managed care enrollment have been established. If manual managed care enrollment is needed, send an email to the PES mailbox.

Pending at PSU — Enter “Yes” or “No.”

Pending at MCO — Enter “Yes” or “No.”

Pending at MEPD — Enter “Yes” or “No.”

Comments — Enter any comments relevant to the actions taken.

The STAR+PLUS Loss of Eligibility Report is a monthly report. PSU staff are required to research, resolve and respond to the requestor within 14 days of receipt. (The fact that completion of the report itself is due within 14 days of receipt does not negate policy regarding denial notifications. Refer to Section 3622, Notification Requirements. The notification must still be sent within two business days.)

Note: SASO files used by PES staff to produce this report are a snapshot in time and may not reflect registrations at the point of receipt.

Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language

Revision 23-4; Effective Dec 7, 2023

Program Support Unit (PSU) staff must use Appendix IV, Form H2065-D STAR+PLUS HCBS Program Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services, and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment not covered in Appendix IV.

Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.

Denial and Termination Language

This table contains Reason for Denial and Comments field language for Form H2065-D and Form H2065-DS generated for denials and terminations.

PSU staff must enter the associated STAR+PLUS Program Support Unit Operational Procedures Handbook (SPOPH) section supporting the denial reason on Form H2065-D and H2065-DS, listed in the SPOPH Section column.

Purpose for Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSPOPH SectionService Authorization System Online (SASO) Code
Unable to LocateYou are not eligible for STAR+PLUS HCBS program because HHSC staff or your health plan cannot locate you to complete the assessment required for the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque el personal de la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.PSU staff must not enter comments language.6300.636 – Individual’s Whereabouts Unknown
Voluntarily Declined ServicesYou are not eligible for STAR+PLUS HCBS program because you voluntarily withdrew from the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque abandonó voluntariamente el programa.PSU staff must not enter comments language.6300.305 – Client Requests Service Termination
Enrolled in Another Medicaid Waiver ProgramYou are not eligible for STAR+PLUS HCBS program. 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 STAR+PLUS HCBS. 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 a la vez.

You are not eligible for STAR+PLUS HCBS program. 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); Home and Community Based Services – Adult Mental Health (HCBS-AMH);  MDCP; Texas Home Living (TxHmL)]. STAR+PLUS HCBS program cannot be authorized. You can only be enrolled in one Medicaid waiver program at a time.

Usted no reúne los requisitos para el programa STAR+PLUS HCBS. 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 para la Salud Mental del Adulto (HCBS-AMH); MDCP; Programa de Texas para Vivir en Casa (TxHmL)]. No se puede autorizar el programa STAR+PLUS HCBS. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez.

611039 – Other
Financial EligibilityYou are not eligible for STAR+PLUS HCBS program because you do not meet the financial criteria necessary for the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no cumple los criterios económicos necesarios para participar en el programa.

Call 2-1-1 if you have questions about the Medicaid application process.

Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid.

6300.406 – Client Denied Medicaid Eligibility
Declined AssessmentYou are not eligible for STAR+PLUS HCBS program because you did not let your health plan complete the assessment required for the program. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no permitió que el plan médico realizara la valoración que requiere el programa.PSU staff must not enter comments language.611039 – Other
Does Not Have an Unmet Need for MAOYou are not eligible for STAR+PLUS HCBS program because you do not need services offered through the program. Usted no puede recibir los servicios del programa HCBS de STAR+PLUS porque no los necesita.PSU staff must not enter comments language.611013 – no unmet need (Six hour)
Does Not Have an Unmet Need for SSIYou are not eligible for STAR+PLUS HCBS program because you do not need services offered through the program.

Usted no puede recibir los servicios del programa HCBS de STAR+PLUS porque no los necesita.

Your provider services will continue uninterrupted.

Los servicios de su proveedor continuarán sin interrupción.

611013 – no unmet need (Six hour)
Failure to Obtain Physician SignatureYou are not eligible for STAR+PLUS HCBS program because your doctor didn’t tell us you need the level of care provided in a nursing home. Usted no puede recibir los Servicios en el Hogar y en la Comunidad (HCBS) de STAR+PLUS porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.PSU staff must not enter comments language.6300.839 – Other
Medical Necessity and Level of CareReason for Denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).You are not eligible for STAR+PLUS HCBS program. See the Reason for Denial text box on page 1 of this form and the STAR+PLUS HCBS Program Medical Necessity Denial Attachment for more information. Usted no reúne los requisitos del programa HCBS de STAR+PLUS. Para más información, vea el cuadro “Motivo de la denegación” en la página 1 de este formulario, así como el anexo “Denegación por no existir necesidad médica” del programa HCBS de STAR+PLUS.6300.508 – Loses Level-of-Care (Medical Necessity)
Exceeding the ISP Cost LimitYou are not eligible for STAR+PLUS HCBS program because the cost of your individual service plan exceeds the maximum amount allowed. Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque el costo de su plan individual de servicios excede la cantidad máxima permitida.PSU staff must not enter comments language.6300.718 – Exceeds Cost Ceiling
Failure to Return Form H1200You are not eligible for STAR+PLUS HCBS program because you did not return the Medicaid application. Usted no puede recibir Servicios en el Hogar y en la Comunidad (HCBS) de STAR+PLUS porque no entregó su solicitud de Medicaid.

Call 2-1-1 if you have questions about the Medicaid application process.

Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid.

6300.406 – Client Denied Medicaid Eligibility  
MFP NF Discharge Prior to Eligibility DeterminationYou are not eligible for the STAR+PLUS HCBS program because you left the nursing facility before HHSC could determine program eligibility.

Usted no reúne los requisitos para recibir servicios del programa de HCBS de STAR+PLUS porque abandonó el centro de reposo antes de que la HHSC pudiera determinar si reunía los requisitos del programa    
PSU staff must not enter comments language.3200N/A
Institutional Stay Over 90 DaysYou are not eligible for STAR+PLUS HCBS program 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 programa HCBS de STAR+PLUS 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 STAR+PLUS HCBS program services while an in-patient of a [Select one: hospital; nursing facility; or intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del programa HCBS de STAR+PLUS mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; or un centro de atención intermedia para personas con discapacidad intelectual].
6300.203 – Admitted to Institution
Moved Out of StateYou are not eligible for STAR+PLUS HCBS program because you are not a Texas resident.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque no reside en Texas.
PSU staff must not enter comments language.611001 – Client Leaves the State/County (Catchment Area)
Under 21You are not eligible for STAR+PLUS HCBS because you are 20 or younger.

Usted no puede recibir servicios del programa HCBS de STAR+PLUS porque es menor de 21 años.
PSU staff must not enter comments language.611039 – Other
OtherPSU staff must contact supervisor.PSU staff must contact supervisor.6300.1039 – Other

Approval Language

This table contains Comments field language for Form H2065-D and Form H2065-DS generated for approvals.

Purpose for Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSPOPH SectionService Authorization System Online (SASO) Code
Medicaid Eligibility Reinstated within Six MonthsN/AYour Medicaid was reinstated on [DATE]. Your STAR+PLUS HCBS program services will continue without interruption. Sus beneficios de Medicaid fueron restablecidos el [DATE]. 

Usted seguirá recibiendo servicios del programa HCBS de STAR+PLUS sin interrupción.
N/AN/A
Initial Form H2065-D for MFP to CommunityN/AYou’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program services will begin. Usted cumple los requisitos del programa STAR+PLUS HCBS. 

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 STAR+PLUS HCBS.
N/AN/A
Initial Form H2065-D for SSI MFP to AFC or ALFN/AYou’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program 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 STAR+PLUS HCBS.

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 STAR+PLUS HCBS. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.
N/A N/A
Initial Form H2065-D for MAO MFP to AFC or ALFN/AYou’re eligible for the STAR+PLUS HCBS program. Your services won’t start until you agree with your health plan on a date for you to leave your nursing home. Stay in the nursing home until you and your health plan agree on a date to leave. This makes sure services are in place when you leave the nursing home. You will receive another notice telling you when your STAR+PLUS HCBS program 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 STAR+PLUS HCBS.

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 STAR+PLUS HCBS. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.
N/A N/A
Room and Board and CopaymentN/AYou 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 N/A

PSU staff must enter “Pending” and “Calculando” in the Copayment fields on the English and Spanish versions of Form H2065-D, respectively, if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist has not provided copayment amounts at the time Form H2065-D is being generated.

Appendix VII, Acronyms

Revision 19-7; Effective June 3, 2019

The following acronyms are used in the STAR+PLUS Home and Community Based Services (HCBS) Program.

Acronym Description
AA Adaptive Aids
ADL Activity of Daily Living
AFC Adult Foster Care
AL Assisted Living
ALF Assisted Living Facility
AO Agency Option
APS Adult Protective Services
CAP Corrective Action Plan
CARE Client Assignment and Registration
CAS Community Attendant Services
CBA Community Based Alternatives
CCAD Community Care for Aged and Disabled
CCSE Community Care Services Eligibility
CCP Comprehensive Care Program
CDS Consumer Directed Services
CFC Community First Choice
CFR Code of Federal Regulations
CHIP Children's Health Insurance Program
CLASS Community Living Assistance and Support Services
CMPAS Client Managed Personal Attendant Services
CMS Claims Management System
CMS Centers for Medicare and Medicaid Services
CNA Certified Nursing Assistant
COLA Cost of Living Adjustment
CRU Centralized Representation Unit
CSHCN Children with Special Health Care Needs
CSIL Community Services Interest List
DAC Disabled Adult Child
DAHS Day Activity and Health Services
DBMD Deaf Blind with Multiple Disabilities
DDS Disability Determination Services
DDU Disability Determination Unit
DER Data Entry Representative
DFPS Department of Family and Protective Services
DIA Diagnosis
DID Determination of Intellectual Disability
DIU Data Integrity Unit
DME Durable Medical Equipment
DOB Date of Birth
DOD Date of Death
DR Designated Representative
DSHS Department of State Health Services
ERS Enrollment Resolutions Services
ERS Emergency Response Service
FBR Federal Benefit Rate
FC Family Care Title XX
FFS Fee-for-Service
FH Fair Hearing
FHO Fair Hearings Officer
FMSA Financial Management Services Agency
GR General Revenue
HCBS Home and Community Based Services
HCS Home and Community-based Services
HCSS Home and Community Support Services
HCSSA Home and Community Support Services Agency
HDM Home-Delivered Meals
HEART Health and Human Services Enterprise Administrative Report and Tracking System
HHS Health and Human Services
HHSC Health and Human Services Commission
HICAP Health Information Counseling and Advocacy Program
HIPAA Health Insurance Portability and Accountability Act
HIPP Health Insurance Premium Payment Program
HMA Health Maintenance Activity
IADL Instrumental Activity of Daily Living
ICF/IID Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions
IDD Intellectual or Developmental Disability
IDT Interdisciplinary Team
ILM Interest List Management
IME Incurred Medical Expense
ISP Individual Service Plan
LAR Legally Authorized Representative
LCSW Licensed Clinical Social Worker
LIDDA Local Intellectual and Developmental Disability Authority
LOC Level of Care
LOS Level of Service
LTC Long Term Care
LTC-R Long Term Care Regulatory
LTSS Long Term Services and Supports
LVN Licensed Vocational Nurse
MAO Medical Assistance Only
MBI Medicaid Buy-In
MC Managed Care
MCO Managed Care Organization
MCCO Managed Care Compliance & Operations
MDCP Medically Dependent Children Program
MDS Minimum Data Set
Med ID Medicaid Identification Card
MEPD Medicaid for the Elderly and People with Disabilities
MERP Medicaid Estate Recovery Program
MESAV Medicaid Eligibility Service Authorization Verification
MFP Money Follows the Person
MFPD Money Follows the Person Demonstration
MHM Minor Home Modification
MMP Medicare-Medicaid Plan
MN Medical Necessity
MN/LOC Medical Necessity and Level of Care
MRSA Medicaid Rural Service Area
MSHCN Members with Special Health Care Needs
NF Nursing Facility
OT Occupational Therapy
OTA Occupational Therapy Assistance
PACE Program of All-inclusive Care for the Elderly
PAS Personal Assistance Services
PCN Patient Control Number
PCP Primary Care Provider;
PCS Personal Care Services
PCS Provider Claims Services
PDN Private Duty Nursing
PES Program Enrollment and Support
PHC Primary Home Care
PNA Personal Needs Allowance
POC Plan of Care
PPECC Prescribed Pediatric Extended Care Center
PPS Premiums Payable System
PSU Program Support Unit
PT Physical Therapy
PTA Physical Therapy Assistance
QIT Qualified Income Trust
QMB Qualified Medicare Beneficiary
R&B Room and Board
RN Registered Nurse
RSDI Retirement and Survivors Disability Insurance
RUG Resource Utilization Group
SASO Service Authorization System Online
SC Service Code
SCSA Significant Change in Status Assessment
SDX State Data Exchange
SE Supported Employment
SG Service Group
SLMB Specified Low-Income Medicare Beneficiaries
SNAP Supplemental Nutrition Assistance Program
SO State Office
SOC Start of Care
SOLQ State On-Line Query
SPT Service Planning Team
SRO Service Responsibility Option
SSA Social Security Administration
SSI Supplemental Security Income
SSN Social Security Number
SSPD Special Services to Persons with Disabilities
ST Speech Therapy
STAR State of Texas Access Reform
STAR+PLUS State of Texas Access Reform Plus
STAR+PLUS HCBS program State of Texas Access Reform Plus Home and Community Based Services program
STS Supplemental Transition Support
TAC Texas Administrative Code
TANF Temporary Assistance to Needy Families
TAS Transition Assistance Services
TDI Texas Department of Insurance
THStep-CCP Texas Health Steps – Comprehensive Care Program
TIERS Texas Integrated Eligibility Redesign System
TMHP Texas Medicaid & Healthcare Partnership
TOA Type of Assistance
TP Type Program
TPR Third-Party Resource
TW Texas Works
TxHmL Texas Home Living
UAP Unlicensed Assistive Person
UMCC Uniform Managed Care Contract
UMCM Uniform Managed Care Manual
WTPY Wire Third Party Query

Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program

Revision 18-0; Effective September 4, 2018

 

An individual entering the STAR+PLUS Home and Community Based Services (HCBS) program is designated as having high needs status if:

  • the individual is on ventilator care;
  • the individual has high-skilled nursing needs, such as tracheotomy care, wound care, suctioning or feeding tubes; and/or
  • the individual will exceed the individual service plan (ISP) cost limit and has needs that will require special services or service delivery, and the community support/resources have not been identified.

Appendix XXIX, STAR+PLUS Plan Codes

Revision 24-2; Effective May 21, 2024
 

STAR+PLUS Plan Codes

Service AreaPlan NamePlan CodesPlan Codes Dates
BexarWellpoint
Molina 
Superior 
45 
46 
47 
Sept. 1, 2011 
Sept. 1, 2011 
Sept. 1, 2011 
DallasMolina 
Superior 
9F 
9H 
March 1, 2012 
March 1, 2012 
El PasoWellpoint
Molina 
34
33
March 1, 2012 
March 1, 2012 
HarrisWellpoint
United Healthcare 
Molina 
7P
7R
7S
Sept. 1, 2011 
Sept. 1, 2011 
Sept. 1, 2011 
HildagoCigna-HealthSpring 
Molina 
Superior
H7 
H6 
H5
March 1, 2012 – Dec. 31, 2021 
March 1, 2012 
March 1, 2012
JeffersonWellpoint
United Healthcare 
Molina 
8R 
8S 
8T
Sept. 1, 2011 
Sept. 1, 2011 
Sept. 1, 2011 
LubbockWellpoint
Superior 
5A 
5B 
March 1, 2012 
March 1, 2012 
Medicaid Rural Service Area (RSA) West Texas Wellpoint
Superior 
W5 
W6 
Sept. 1, 2014 
Sept. 1, 2014 
Medicaid RSA Northeast Texas Cigna-HealthSpring
Molina 
United Healthcare 
N3
P2 
N4
Sept. 1, 2014 – Dec. 31, 2021 
Jan 1, 2022 
Sept. 1, 2014 
Medicaid RSA Central Texas Superior
United Healthcare 
C4
C5
Sept. 1, 2014 
Sept. 1, 2014 
Nueces United Healthcare 
Superior 
85 
86 
Sept. 1, 2011 
Sept. 1, 2011 
Tarrant Wellpoint
Cigna-HealthSpring 
Molina 
69 
6C 
P1 
Sept. 1, 2011 
Sept. 1, 2011 – Dec. 31, 2021 
Jan. 1, 2022
Travis Wellpoint
United Healthcare 
19 
18 
Sept. 1, 2011
Sept. 1, 2011 

Medicare-Medicaid Plan (MMP) Codes

Service AreaPlan NamePlan CodesPlan Code Dates
BexarWellpoint
Molina 
Superior 
4F 
4G 
4H 
Sept. 1, 2015
Sept. 1, 2015
Sept. 1, 2015
DallasMolina 
Superior 
9J 
9K
Sept. 1, 2015
Sept. 1, 2015
El PasoWellpoint
Molina 
3G 
3H 
Sept. 1, 2015
Sept. 1, 2015
HarrisWellpoint
United Healthcare 
Molina 
7Z 
7Q 
7V 
Sept. 1, 2015
Sept. 1, 2015
Sept. 1, 2015
HildagoCigna-HealthSpring 
Molina 
Molina 
Superior 
H8 
H9 
P3 
HA 
Sept. 1, 2015 – Dec. 31, 2021
Sept. 1, 2015
Jan. 1, 2022
Sept. 1, 2015
Tarrant Wellpoint
Cigna-HealthSpring
6F
6G
Sept. 1, 2015
Sept. 1, 2015 – Dec. 31, 2021

Appendix XXX, Relocation Function

9-2017

Purpose

The relocation function is a component of service coordination. The primary purpose of the relocation function is to support the transition of members and future members who desire to move from an institution to the community. A relocation specialist (RS) works for an entity contracted with a managed care organization (MCO) to perform the relocation function.

Overview of Relocation Function

  • Conduct outreach and education to nursing facilities and residents on options for receiving long-term services and supports (LTSS) in the community;
  • Identify members interested in relocating;
  • Respond to referrals for relocation and conduct relocation assessments;
  • Develop and implement person-centered relocation plans;
  • Coordinate housing and non-covered community services, as mutually agreed;
  • Provide support on day of relocation and conduct follow-up; and
  • Collect data on relocations as specified by the Texas Health and Human Services Commission and/or MCOs.

Relocation Tasks

MCO RS Both Conduct Outreach and Education
    X Conduct regular visits to nursing facilities to educate individuals in the facility, family members and potential referral sources about community-based services, including STAR+PLUS Home and Community Based Services (HCBS), and the availability of assistance with relocation. Educate potential referral sources regarding the availability of STAR+PLUS HCBS.
    X Provide group and individual training to nursing facility staff on relocation services.
  X   Encourage a referral to a Local Contact Agency for residents interested in relocating.
MCO RS Both Identify and Refer Individuals Interested in Relocating (non-Minimum Data Set Referrals)
    X If an RS learns of a member’s desire to move to the community, the RS must notify the member’s MCO. If an MCO learns of a member’s desire to move to the community, the MCO must notify the RS. Either party has three business days to notify the other party.
  X   Upon receipt of referral, the RS must make an initial contact face-to-face or by telephone within five business days to schedule a relocation assessment. Initial contact must be with the member or the member’s authorized representative (AR). An AR such as a family member or friend who is knowledgeable of the member’s situation and services may be engaged to support information provided by the member. 
X     The MCO service coordinator must contact the member to schedule an assessment for STAR+PLUS HCBS within 14 business days of notification by the RS. The MCO has 45 days to complete all assessment activities related to STAR+PLUS HCBS eligibility.
  X   Provide the appropriate Local Intellectual and Developmental Disability Authority (LIDDA) with contact information for members interested in relocating who have an Intellectual or Developmental Disability (IDD). Provide notification to the appropriate MCO that a referral was made to the LIDDA.
MCO RS Both Respond to Referrals for Relocation and Conduct Relocation Assessment
  X   When contacted by the MCO via Form 1579, Referral for Relocation Services, or after referral is received from another source, conduct a face-to-face relocation assessment with the member or AR within 14 business days. An AR such as a family member or friend who is knowledgeable of the member’s situation and services may be engaged to support information provided by the member.  The assessment includes, but is not limited to:
  • goals of the member with regard to community living;
  • preferences for post-relocation housing;
  • information regarding informal support;
  • information regarding finances and need for support;
  • need for post-relocation non-waiver supports;
  • history of unsuccessful relocation attempts and reasons attempts were not successful; and
  • barriers to relocation.
  X   Share results from assessment with the MCO.
    X Develop a person-centered relocation plan with the member or AR and others whom he/she chooses to have involved.
    X Advocate with nursing facility staff, RS and service coordinator(s) to support the member’s needs, preferences and goals.
    X Through their respective assessments, the MCO service coordinator and RS identify and include in the MCO service plan and/or RS’ transition plan non-covered community services, including, but not limited to:
  • help setting up a utility or telephone account;
  • non-medical transportation, including mainline, special transit and local transportation providers;
  • start-up groceries, as needed; or
  • banking, bill payment and direct deposit.
    X Maintain regular, open communication with all parties who are involved in the relocation process.
MCO RS Both Coordinate Housing, Non-Medicaid Community Supports and Discharge
    X If the member is in need of housing, the RS is primarily responsible to help secure affordable, accessible and integrated housing consistent with the resident’s preferences. The RS assists the member in applying for:
  • Project Access, as indicated;
  • Section 811 Project Rental Assistance, as available; and
  • other affordable housing options, as necessary.
X     If the member is interested in assisted living, personal care homes or adult foster care, the MCO service coordinator will review options available among contracted providers.
    X Assist the member in accessing community supports, such as food banks, utility assistance, emergency rental assistance and emergency SNAP.
    X Participate in the discharge planning process with the member or AR, service coordinator(s), RS and others important to the member.
X     MCOs will negotiate and set the discharge date in coordination with the RS and other community and social supports, as necessary.
    X If an MCO or RS becomes aware of a change to the discharge date, the MCO or RS must notify the other party immediately.
MCO RS Both Provide Support on Relocation Day and Follow-up
    X Coordinate with all parties to ensure everything is in place at the time of discharge.
    X Help facilitate the member’s notification to Social Security of the member’s new address as soon as possible after relocating to the community.
X     The MCO service coordinator will remind nursing facility staff to transfer Medicaid benefits from the facility to the community.
    X Be present at new address on relocation day to ensure all services are in place.  Assist in setting up household, as needed.
    X

Notify the other party if the member does not have all necessary Medicaid and non-Medicaid supports in place on the day of relocation.

    X Provide follow up, which may include:
  • determining if there are unresolved issues related to transfer of benefits, health, emotional well-being, etc.;
  • communicating all unresolved medical issues to the MCO service coordinator; and
  • assisting the member in addressing unmet needs.
  X   Contact the member at least seven times over the course of 90 days post-relocation to ensure a successful transition to the community. Notify the MCO if the member has an unmet need.

Minimum Qualifications

An MCO must offer a contract to provide the relocation function to an entity with at least five years contracting with the state to provide relocation functions as of Sept. 1, 2016, to members transitioning from institutions to Medicaid community-based LTSS.

An MCO may offer a contract to a new entity to provide the relocation function. The new entity must meet all of the following qualifications:

  • Adherence to Health Insurance Portability and Accountability Act (HIPAA) compliant data management requirements and other stipulations of the MCO;
  • Experience identifying barriers to relocation for members who express an interest in moving from nursing facilities in Texas to a home and community-based setting;
  • Knowledge of community resources for members with disabilities of all ages and how to access those resources;
  • Knowledge of community and federal housing resources and how to access those resources, as appropriate;
  • Knowledge of Medicaid, including, but not limited to, Medicaid managed care, long term services and supports, eligibility requirements and how to apply and qualify for Medicaid;
  • Ability to hire, train, supervise and direct RS staff that ensures the successful transition of members from nursing facilities. The entity is responsible for ensuring any RS is not listed in the HHSC employee misconduct registry, Inspector General (IG) list of excluded entities and individuals, and HHSC do not hire registries. The entity must conduct a fingerprint background check and share the results with the MCO prior to hiring an RS;
  • Two years of experience developing transition plans for members; and
  • Three years of experience working directly with people with disabilities of all ages or the entity must have at least three years of experience subcontracting with an entity described above to provide the relocation function.

Appendix XXXIII, STAR+PLUS HEART Naming Conventions

Revision 23-4; Effective Dec. 7, 2023

This appendix outlines the screenshots Program Support Unit (PSU) staff must upload to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

PSU staff must use the HEART Naming Conventions below when uploading documents to the HEART case record. Refer to Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, for TxMedCentral naming convention instructions.

PSU staff must add a sequence number after the naming convention when more than one of the same form or screenshot is uploaded. For example, PSU staff must name the first Form H1746-A sent or received as 1746_1, the second form sent or received as 1746_2, and the third form sent or received as 1746_3.

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 while completing the case.

Interest List Release (ILR)

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
CSIL Closure ScreenshotCSIL CLOSUREYes
Form 2442 (English)2442*
Form 2442-S (Spanish)2442-S*
Form 2442 Screenshot of Upload to TxMedCentralUse TxMedCentral Naming Convention*
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1700-1 (if received through TMHP LTCOP)LTCOP ISPYes
Form H1700-1 (if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826H1826*
Form H2053-B2053B*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065*
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming Convention*
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMED*
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Form H36753675*
Form H3676-AUse TxMedCentral Naming ConventionYes
Form H3676-A Upload to TxMedCentral3676A TXMEDYes
Form H3676-BUse TxMedCentral Naming ConventionYes
TIERS Copayment Budget ScreenshotTIERS COPAY*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CRUCRU EMAIL*
Emails to and from CCSECCSE EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from IDD Unit IDD EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*
MEPD Communication ToolMEPD EMAIL*

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

Upgrades

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1700-1 (if received through TMHP LTCOP)LTCOP ISPYes
Form H1700-1 (if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826H1826*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
TIERS Copayment Budget ScreenshotTIERS COPAY*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CRUCRU EMAILS*
MEPD Communication ToolMEPD EMAIL*

Money Follows the Person (MFP)

ItemHEART Naming ConventionRequired
TIERS Individual- Medicaid History ScreenshotTIERS MEYes
TIERS Individual- Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
CSIL Closure ScreenshotCSIL CLOSUREYes
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1700-1 (if received through TMHP LTCOP)LTCOP ISPYes
Form H1700-1(if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826H1826*
Form H2053-B2053B*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
TIERS Copayment Budget ScreenshotTIERS COPAY*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CRUCRU EMAILS*
Emails to and from CCSECCSE EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*
Emails to and from the MFPD Reporting Coordinator365-DAY EMAIL*
MEPD Communication ToolMEPD EMAIL*

Annual Reassessment

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual- Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO EN*
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
Form 26062606*
Form 2606-S2606-S*
Form H1826H1826*
Form H1700-1 (if received through TMHP LTCOP)LTCOP ISPYes
Form H1700-1(if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming Convention*
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMED*
TIERS Copayment Budget ScreenshotTIERS COPAY*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*

Transition to Adult Programs (MDCP Age-Out)

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
Form 21142114*
Form 26062606*
Form 2606-S2606-S*
Form H1200 (Page 1, Section A, You and Your Spouse, and Page 19, Signature Page)1200*
Form H1700-1 (if received through TMHP LTCOP)LTCOP ISPYes
Form H1700-1(if received through TxMedCentral)Use TxMedCentral Naming ConventionYes
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826H1826*
Form H2053-B2053B*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Form H21162116*
Form H36753675*
Form H3676-AUse TxMedCentral Naming ConventionYes
Form H3676-A Upload to TxMedCentral3676A TXMEDYes
Form H3676-BUse TxMedCentral Naming ConventionYes
TIERS Copayment Budget ScreenshotTIERS COPAY*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CCSECCSE EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from Higher Needs CoordinatorHN EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
Emails to and from PSORTPSORT EMAIL*
Emails to and from STAR Kids PSUPSU EMAIL*
Emails to and from URUR EMAIL*
Emails to and from IDD UnitIDD EMAIL*
MEPD Communication ToolMEPD EMAIL*

Denials and Terminations

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
SASO Enrollment ScreenshotSASO EN*
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
CSIL Closure ScreenshotCSIL CLOSURE*
Fair Hearing Options for STAR+PLUS HCBS Program DenialsMN DENIAL ATCH*
Form 26062606*
Form 2606-S2606-S*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826H1826*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065*
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming Convention*
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMED*
Form H2067-MCUse TxMedCentral Naming Convention*
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMED*
Emails for PSU QA ProcessQA EMAIL*
Emails to and from CRUCRU EMAIL*
Emails to and from ERSERS EMAIL*
Emails to and from IDD UnitIDD EMAIL*
Emails to and from ILM UnitILM EMAIL*
Emails to and from MCCOMCCO EMAIL*
MEPD Communication ToolMEPD EMAIL*

Note: PSU staff must upload Form H2067-MC or Form H2065-D in the HEART case record, as appropriate.

Fair Hearings

ItemHEART Naming ConventionRequired
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
Form 26062606*
Form 2606-S2606-S*
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H1826Form H1826*
Form H2065-D Generated in TMHP LTCOP (English and Spanish)2065Yes
Form H2065-D Generated Manually (English and Spanish)Use TxMedCentral Naming ConventionYes
Form H2065-D Screenshot of Upload to TxMedCentral2065 TXMEDYes
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Form H48004800*
Form H4800-A4800A*
Form H4800-D4800D*
Form 4801FH COVER LTRYes
Form H48034803Yes
Form H48064806*
Form H48074807*
Appendix XX for All DenialsELIGIBILITY TACYes
Copy of Handbook Section Referenced on Form H2065-DSPOPH [####]Yes
Fair Hearing Options for STAR+PLUS HCBS Program DenialsMN DENIAL ATCH*
Notice of Hearing Officer’s DecisionAPPEAL DECISION LTRYes
HHSC Benefits Portal Screenshot of Hearing Officer’s DecisionTIERS APPEAL DECISIONYes
Emails to and from DER ClerkCLERK EMAIL*
Emails to and from CRUCRU EMAIL*
Emails to and from ERSERS EMAIL*
MEPD Communication ToolMEPD EMAIL*

Disenrollment

ItemHEART Naming ConventionRequired
TIERS Individual - Medicaid History ScreenshotTIERS MEYes
TIERS Individual - Managed Care ScreenshotTIERS MCYes
SASO Enrollment ScreenshotSASO ENYes
SASO Service Plan ScreenshotSASO SP*
SASO Service Authorization ScreenshotSASO SAYes
SASO Medical Necessity ScreenshotSASO MNYes
Form H1746-A (form alone or with fax confirmation page)1746*
Form H1746-A Fax Confirmation (if confirmation page only)1746 CONF*
Form H2067-MCUse TxMedCentral Naming ConventionYes
Form H2067-MC Screenshot of Upload to TxMedCentral2067 TXMEDYes
Medicaid Managed Care Member Disenrollment FormDISENFORMYes
Emails for PSU QA ProcessQA EMAIL*
Emails to and from MCCOMCCO EMAILYes
MEPD Communication ToolMEPD EMAIL*

Appendix XXXIV, STAR+PLUS MCOHub Naming Conventions

Revision 24-2; Effective May 21, 2024

The MCOHub is a secure Internet bulletin board that the Texas Health and Human Commission (HHSC) Program Support Unit (PSU) staff and the managed care organization (MCO) use to share information securely. MCOHub uses specific naming conventions only for the documents listed below. PSU staff and the MCO must follow these naming conventions any time either the MCO or PSU staff uploads one of the following documents to the MCOHub.

Form H3676, Managed Care Pre-Enrollment Assessment Authorization (PDF)

PSU staff and the MCO must upload Form H3676 to the SPW folder. PSU staff and the MCO must not upload this form to any other folder. An M or S is added to the sequence number to indicate if the MCO or PSU staff uploads the form to MCOHub. An M indicates the MCO. An S indicates PSU staff. 

PSU staff must enter two commas after the last letter of the individual or applicant’s last name if the last name contains two letters. For example A or B,,. PSU staff must enter one comma after the last letter of the individual or applicant’s last name if the last name contains three letters. For example, ABC,

Two-Digit Plan Identification (ID)Form No.Member ID, Medicaid No. or Social Security No. (SSN)First Four Letters of Member's Last NameSection No.Sequence No. of Form Examples
# #3676123456789ABCDA or B1S, 2S, 3S or 1M, 2M, 3M

Examples: 

  • The naming convention for this form must be ##_3676_123456789_ABCD_A_1S when PSU staff initially completes and uploads Section A.
  • The naming convention for this form must be ##_3676_123456789_ABCD_A_2S if PSU staff completes and uploads Section A of this form a second time.
  • The naming convention for this form must be ##_3676_123456789_ABCD_B_1M when the MCO initially completes and uploads Section B as a response to Section A. 
  • The naming convention for this form must be ##_3676_123456789_ABCD_B_2M if the MCO completes and uploads Section B of this form a second time.

Form H1700-1, STAR+PLUS HCBS Program Individual Service Plan (PDF)

The MCO must:

  • Complete and upload Form H1700-1 to the individual service plan (ISP) folder in the MCOHub for non-members, age-outs, and nursing facility (NF) residents transitioning to the STAR+PLUS Home and Community Based Services (HCBS) program.
  • Complete and submit Form H1700-1 to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) for members in the community. 

The MCO must not upload Form H1700-1 to any other folder in the MCOHub. The MCO is not required to upload Form H1700-1 to the MCOHub if submitted through the TMHP LTCOP.

Two-Digit Plan IDForm No.Member ID, Medicaid No. or SSNFirst Four Letters of Member's Last NamePage No. of Form H1700-1Sequence No. of Form Examples
# #1700123456789ABCD11, 2, 3

Examples:

  • The naming convention for this form must be ##_1700_123456789_ABCD_1_1 when the MCO initially completes and uploads this form.
  • The naming convention for this form must be ##_1700_123456789_ABCD_1_2 if the MCO completes and uploads this form a second time.

Form H2067-MC, Managed Care Programs Communication (PDF)

PSU staff and the MCO must complete and upload Form H2067-MC to the SPW folder in the MCOHub. PSU staff and the MCO must not upload this form to any other folder. An M or S is added to the sequence number to indicate if the MCO or PSU staff uploads the form to the MCOHub. An M indicates the MCO. An S indicates PSU staff.

PSU staff must enter two commas after the last letter of the individual or applicant’s last name if the last name contains two letter, for example, AB,,. PSU staff must enter one comma after the last letter of the individual or applicant’s last name if the last name contains three letters, such as, ABC,.

Two-Digit Plan IDForm No.Member ID, Medicaid No. or SSNFirst Four Letters of Member's Last NameSection No.Sequence No. of Form Examples
# #2067123456789ABCD 1S, 2S, 3S or 1M, 2M, 3M

Examples:

  • The naming convention for this form must be ##_2067_123456789_ABCD_1S if PSU staff initially completes and uploads this form.
  • The naming convention for this form must be ##_2067_123456789_ABCD_2S if PSU staff completes and uploads this form a second time.
  • The naming convention for this form must be ##_2067_123456789_ABCD_1M if the MCO initially completes and uploads this form.
  • The naming convention for this form must be ##_2067_123456789_ABCD_2M if the MCO completes and uploads this form a second time.

Money Follows the Person (MFP)

PSU staff must use a separate naming convention to address the use of Form H2067-MC (PDF) for NF residents who request transition to the community under the STAR+PLUS Home and Community Based Services (HCBS) program. These individuals and applicants are considered expedited cases for application to the STAR+PLUS HCBS program. The acronym for Money Follows the Person is MFP and has been added to the section number in the naming convention to achieve rapid identification.

An M or S is added to the sequence number to indicate if the MCO or PSU staff uploads the form to the MCOHub.  An M indicates the MCO. An S indicates PSU staff.

PSU staff must enter two commas after the last letter of the individual or applicant’s last name if the last name contains two letter, such as, AB,,. PSU staff must enter one comma after the last letter of the individual or applicant’s last name if the last name contains three letters, such as ABC,.

Two-Digit Plan IDForm No.Member ID, Medicaid No. or SSNFirst Four Letters of Member's Last NameSection No.Sequence No. of Form Examples
# #2067123456789ABCDMFP1S, 2S, 3S or 1M, 2M, 3M

Examples:

  • The naming convention for this form must be ##_2067_123456789_ABCD_MFP_1S if PSU staff initially completes and uploads this form.
  • The naming convention for this form must be ##_2067_123456789_ABCD_MFP_2S if PSU staff completes and uploads this form a second time.
  • The naming convention for this form must be ##_2067_123456789_ABCD_MFP_1M if the MCO initially completes and uploads this form.
  • The naming convention for this form must be ##_2067_123456789_ABCD_MFP_2M if the MCO completes and uploads this form a second time.

Form 2442, Notification of Interest List Release Closure (PDF)

PSU staff must complete and upload Form 2442 to the SPW folder in the MCOHub. PSU staff must not upload this form to any other folder.

PSU staff must enter two commas after the last letter of the individual’s last name if the last name contains two letters, such as, AB,,. PSU staff must enter one comma after the last letter of the individual’s last name if the last name contains three letters, such as, ABC,.

Two-Digit Plan ID<