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:

• Form H1200, Application for Assistance – Your Texas Benefits; and
• Form H1746-A, MEPD Referral Cover Sheet.

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.

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:

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, §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) §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.

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) 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.

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:

• complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
• upload Form H3676 to TxMedCentral in the MCO’s SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions.

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:

• Form H2053-A, STAR+PLUS Selection Letter;
• Form H3675, Application Acknowledgement;
• Form H2053-B, Health Plan Selection;
• Form H1200, Application for Assistance – Your Texas Benefits;
• Appendix XII, STAR+PLUS HCBS Program Description;
• STAR+PLUS Comparison Charts;
• STAR+PLUS Report Cards; and
• a postage-paid envelope.

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, 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 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, 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, 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, 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 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.

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

Code of Federal Regulations (CFR) Section 431.213, Exceptions from advance notice.

The agency may mail a notice not later than the date of action if:

• the agency has factual information confirming the death of a recipient;
• the agency receives a clear written statement signed by a recipient that;
  • he or she no longer wants services; or
  • gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information;
• the recipient has been admitted to an institution where he or she is ineligible under the plan for further services;
• the recipient's whereabouts are unknown and the post office returns agency mail directed to him or her indicating no forwarding address (See Section 431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);
• the agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, state, territory or commonwealth;
• a change in the level of medical care is prescribed by the recipient's physician.

Program Support Unit (PSU) staff must coordinate the termination of Community Care Services Eligibility (CCSE) with the CCSE case manager, 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:

• contact the PSU supervisor to obtain the contact information for the CCSE case manager; 
• email the CCSE case manager 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].” For example, the email subject line for a STAR+PLUS HCBS program termination for Ann Smith would be “STAR+PLUS HCBS Termination for AS”;
  • member’s name;
  • Medicaid ID;
  • start of care (SOC) date for STAR+PLUS HCBS program; 
  • managed care organization (MCO);
  • Form H2065-D, Notification of Managed Care Program Services;
• ensure the Service Authorization System Online (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 18-0; Effective September 4, 2018

For individuals entering the STAR+PLUS Home and Community Based Services (HCBS) program, 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. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCSE service.

It is not necessary to provide an adverse action period prior to closing the authorization in the Service Authorization System Online (SASO).

CCSE services are terminated by the CCSE case manager no later than the day prior to STAR+PLUS HCBS program enrollment. This is crucial since no STAR+PLUS HCBS program individual may receive CCSE and STAR+PLUS HCBS program services on the same day. The CCSE case manager must send:

• Form H2065-A, Notification of Community Care Services, denying ongoing Texas Health and Human Services Commission (HHSC) services to the member; and
• Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring from CCSE to the STAR+PLUS HCBS program.

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:

• Form H2065-A, Notification of Community Care Services, including a notation to the provider in the comments section that the individual is transferring to the STAR+PLUS HCBS program; and
• Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring from CCSE to the STAR+PLUS HCBS program.

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:

• Form H3675, Application Acknowledgement; and
• Appendix XII, STAR+PLUS HCBS Program Description.

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, 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, 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, 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;
• for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist notating the 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, along with Form H1746-A, MEPD Referral Cover Sheet, 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:

• Form H3034, Disability Determination Socio-Economic Report;
• Form H3035, Medical Information Release/Disability Determination; and
• a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment.

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, 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, to PSU staff.

PSU staff fax the signed and completed Form H1200 and Form H1746-A, MEPD Referral Cover Sheet, 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:

• complete the Medical Necessity and Level of Care (MN/LOC) Assessment and submit it to Texas Medicaid & Healthcare Partnership (TMHP) to request medical necessity (MN); and
• upload Form H1700-1, Individual Service Plan (Pg. 1), to TxMedCentral.

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, 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 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.

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 Transfer Scenarios

Revision 18-0; Effective September 4, 2018

3411 Transferring to Another Service Area with Prior Knowledge

Revision 21-4; Effective March 26, 2021

When Program Support Unit (PSU) staff are notified of a transfer from one STAR+PLUS service area to another STAR+PLUS service area, within two business days, the losing PSU staff:

• notify the gaining PSU staff a member is transferring to its service area and provides the following:
  • member name;
  • Social Security number (SSN);
  • Medicaid identification (ID) number;
  • current and future contact information; and
  • date of the move or anticipated move;
• email Form H1700-1, Individual Service Plan (Pg. 1), to the gaining PSU staff;
• notify the Medicaid for the Elderly and People with Disabilities (MEPD) using Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) individuals;
• remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address; and
• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization's (MCO's) SPW folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, and request Form H1700-1 and all forms listed below from the losing MCO:
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
  • the Medical Necessity and Level of Care (MN/LOC) Assessment;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060; and
  • Form H2060-B, Needs Assessment Addendum, as applicable.

Once the gaining PSU staff receive Form H1700-1, PSU staff will confirm all STAR+PLUS HCBS program eligibility. The process is abbreviated since the member already has:

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

The gaining PSU staff coordinates all appropriate activities between the losing PSU staff, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining service area.

The gaining PSU staff maintains contact with the member until the transfer is complete. Within five business days after the transfer is complete, PSU staff:

• send an email to the ERS mailbox notifying ERS the member has moved;
• manually close the current Service Authorization System Online (SASO) records for the losing MCO effective the end of the month the member moves;
• manually update SASO with the gaining MCO's information effective the first day of the month after the move;
• mail Form H2065-D, Notification of Managed Care Program Services, to the member and include the begin and end dates of the individual service plan (ISP) in the Comments section; and
• upload Form H2065-D to TxMedCentral in the MCO's SPW folder, following the instructions in Appendix XXXIV.

Within three business days of notification of the move, ERS disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

Refer to Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for additional information.

3412 Transferring to Another Service Area Without Prior Knowledge

Revision 21-10; Effective October 25, 2021

The losing Program Support Unit (PSU) staff must complete the following activities within two business days of being notified a member has already transferred from one STAR+PLUS service area (SA) to another SA:

• Notify the gaining PSU staff a member has transferred to their SA and provide the member's:
  • name;
  • Social Security number (SSN);
  • Medicaid identification (ID) number;
  • current and future contact information; and
  • date of the move;
• Upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, requesting all forms listed below from the losing MCO:
  • 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 8604, Transition Assistance Services (TAS) Assessment and Authorization;
  • the Medical Necessity and Level of Care (MN/LOC) Assessment;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060; and
  • Form H2060-B, Needs Assessment Addendum, as applicable.
• Fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist for medical assistance only (MAO) members; and
• Advise the MCO to notify the member with Social Security benefits to contact the Social Security Administration (SSA) to change the address.

PSU staff must upload the following documents received from the losing MCO to the gaining MCO to TxMedCentral, following the instructions in Appendix XXXIV, within two business days:

• Form H2067-MC, advising the gaining MCO of the member's SA transfer;
• Form H1700-1;
• Form H1700-2;
• Form H1700-3;
• Form H1700-A1;
• Form 8604;
• the MN/LOC Assessment;
• Form H2060;
• Form H2060-A; and
• Form H2060-B, as applicable.

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

• contact the member by phone to select an MCO from the gaining SA;
• mail the enrollment packet containing:
  • Form H2053-B, Health Plan Selection;
  • STAR+PLUS comparison charts; and
  • STAR+PLUS Report Cards.

The gaining MCO must contact the member within one business day of receipt of Form H2067-MC and begin services within two business days of receipt of Form H2067-MC.

The gaining PSU staff must confirm all STAR+PLUS Home and Community Based Services (HCBS) program eligibility criteria is met upon receipt of Form H1700-1. The process is abbreviated since the member already has:

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

The gaining PSU staff coordinate all appropriate activities between the losing PSU staff, MCOs, member, Enrollment Resolution Services (ERS) Unit staff and other key parties to help ensure a successful transition. PSU staff must track each step of the process through the start of the new STAR+PLUS HCBS program in the gaining SA.

The gaining PSU staff must complete the following activities within two business days of completing the steps above:

• manually close Service Authorization System Online (SASO) records effective the end of the month the member moves;
• manually update SASO with the gaining MCO's information effective the first of the following month in which the move occurred;
• notify the ERS Unit staff by email at HPO_STAR_PLUS@hhsc.state.tx.us. The email to the ERS Unit must include the following information:
  • the member's name;
  • Medicaid identification (ID) number;
  • type of request (i.e., SA change);
  • MN approval date;
  • ISP begin date;
  • ISP end date;
  • MCO;
  • effective date of enrollment; and
  • Form H2065-D;
• upload applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record 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 Appendix XXXI, STAR +PLUS Members Transitioning from an NF in one Service Area to the Community in Another Service Area, for additional information.

3413 Transferring from One MCO to Another Within the Same Service Area

Revision 22-3; Effective Sept. 27, 2022

A member or authorized representative (AR) can request to change managed care organization (MCO) plans as often as they want, but the change cannot be made more than once per month.

The member or AR must contact the Texas Health and Human Services Commission (HHSC) enrollment broker by phone at 800-964-2777 to change from one MCO to another MCO in the same service area (SA). The HHSC enrollment broker must ask if the member is in a hospital or living in a nursing facility (NF). The member is not eligible to change MCO plans until the member has been discharged from the hospital or NF.

MCO enrollment changes become effective based on the date the MCO change is requested and processed in relation to state cutoff. Refer to Appendix XVII, State Cutoff Dates, for additional information on current cutoff dates.

Monthly Plan Changes Report

Enrollment Operations Management (EOM) Unit staff prepares and sends the Monthly Plan Changes Report to Program Support Unit (PSU) staff and the gaining MCOs. PSU staff receive a full list of all plan changes and the MCO receives a list of their members only. The report gives a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have changed MCOs from the previous month.

PSU staff must correct the contract number in the Service Authorization System Online (SASO) to reflect the new MCO contract number for all MCO changes within 14 days of receipt of the Monthly Plan Changes Report. PSU staff must refer to Section 9300, Transfers, for more information on SASO actions.

The losing MCO is responsible for transferring all relevant member information to the gaining MCO, including the individual service plan (ISP) and Medical Necessity and Level of Care (MN/LOC) Assessment. The gaining MCO must notify Managed Care Contracts & Oversight (MCCO) Unit staff if the losing MCO fails to provide member information. MCCO Unit staff may contact PSU staff for assistance in transferring member information to the gaining MCO through TxMedCentral.

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

Refer to Appendix I-E, Monthly Plan Changes Report, for more information on report contents.

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

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:
  • Form 2114, Nine-Month Transition Letter;
  • Form H2053-B, Health Plan Selection;
  • Form H1200, Application for Assistance – Your Texas Benefits;
  • Appendix XII, STAR+PLUS HCBS Program Description;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards.

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

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

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 23-2; Effective May 15, 2023

Program Support Unit (PSU) staff must confirm STAR+PLUS Home and Community Based Services (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 Medical Necessity and Level of Care (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); 
  • Note: A valid MN does not exceed 150 days from the date of TMHP approval. PSU staff must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral requesting the managed care organization (MCO) resubmit 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 follow the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, when uploading documents to TxMedCentral.
• at least one STAR+PLUS HCBS program service is listed on Form H1700-1, Individual Service Plan;
• the ISP does not exceed the allowable cost limit; and
• continued Medicaid financial eligibility in the Texas Integrated Eligibility Redesign System (TIERS).

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

• establish the start of care (SOC) date. The SOC date 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 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;
  • upload Form H2065-D to TxMedCentral following the instructions in Appendix XXXIV; 
  • mail Form H2065-D to the member;
  • notify Enrollment Resolution Services (ERS) Unit staff by email. The email sent to ERS Unit staff must include:
    • an email subject line that reads: "MDCP Transition to STAR+PLUS HCBS for XX [first letter of the member's first and last name]." For example, the email subject line for an MDCP transition into the STAR+PLUS HCBS program for Ann Smith would be "MDCP Transition to STAR+PLUS HCBS for AS";
    • the member's name;
    • Medicaid identification (ID) number;
    • ISP begin and end date for the STAR+PLUS HCBS program;
    • MCO selection and plan code; and
    • Form H2065-D;
  • for medical assistance only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist as notification of the program change from MDCP to the STAR+PLUS HCBS program;
  • coordinate with the Intellectual or Developmental Disability (IDD) Waiver/Community Services/Hospice Utilization Review (UR) Unit staff on the termination date by email if the individual is 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);
  • 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, 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, 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).

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.

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 23-4; Effective Dec. 7, 2023

The managed care organization (MCO) must determine if the individual wants to pursue the STAR+PLUS Home and Community Based Services (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 get the person’s waiver selection within the initial 45-day time frame for assessment. The MCO must notify Program Support Unit (PSU) staff of the individual’s waiver selection by uploading Form H2067-MC, Managed Care Programs Communication, to the MCOHub.

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

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

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, 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:
  • Form H1200, if applicable;
  • Appendix XII, STAR+PLUS HCBS Program Description;
  • Form H2053-B, Health Plan Selection;
  • STAR+PLUS Comparison Charts; and
  • STAR+PLUS Report Cards;
• 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, 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 45^th day that PSU staff mailed Form H1200 to the individual:

• upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, if applicable;
• document in the HEART case record Form H1200 was not received within 45 days;
• upload applicable documents to the HEART case record, following the instructions in Appendix XXXIII; and
• close the HEART case record.

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, 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.

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, from PSU staff:

• Form H1700-1, Individual Service Plan;
• Form H3676 with Section B completed; and
• Form H2067-MC, Managed Care Programs Communication, notifying PSU staff of the NF proposed discharge date.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, 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;
  • 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.

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, 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 Programs Communication, 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.

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.