STAR+PLUS Program Support Unit Operational Procedures Handbook

5000, Medically Fragile Group and General Revenue Funds Process

Revision 25-1; Effective Feb. 19, 2025

An applicant or member’s individual service plan (ISP) cost limit is calculated by Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). It is based upon information the managed care organization (MCO) gathered in the Medical Necessity and Level of Care (MN/LOC) Assessment. Title 1 Texas Administrative Code (TAC) Part 15, Chapter 353, Subchapter M, Chapter 353.1153©(1)(H), STAR+PLUS Home and Community Based Services (HCBS) Program, states the cost of STAR+PLUS HCBS program services on the individual service plan (ISP) should not exceed 202 percent of the cost of care Texas Health and Human Services Commission (HHSC) would pay if the individual was served in a nursing facility (NF).

The MCO must notify the Office of the Medical Director (OMD), Utilization Review (UR) Unit staff and Program Support Unit (PSU) staff when the cost of an ISP exceeds the cost limit. The MCO notifies the OMD, UR and PSU staff by completing the following activities:

  • checking the Over Annual Cost Limit Override for GR and Medically Fragile box within the ISP record in the LTCOP; and
  • uploading Form H2067-MC, Managed Care Programs Communication (PDF), to the MCOHub advising that the ISP submitted in the TMHP LTCOP exceeds the cost limit and is for an applicant or member being assessed for the Medically Fragile group or General Revenue (GR) funds process.

The OMD and UR Unit staff review the ISP to determine if eligibility can be provided through the Medically Fragile group or GR funds process. The Medically Fragile and GR funds process allows an applicant or member to be eligible for the STAR+PLUS HCBS program with an ISP that exceeds the cost limit.

UR Unit staff provide a determination to PSU program managers (PMs) on if an applicant or member meets the criteria for the Medically Fragile group or GR funds process. The determination is provided through an automated email generated from SharePoint. PSU PMs refer determinations to the PSU supervisors for assignment to PSU staff. UR Unit staff provide a separate determination letter to the MCO.

An applicant or member who exceeds the cost limit and is not approved for the Medically Fragile group or GR funds process cannot elect to receive reduced services for entry to the STAR+PLUS HCBS program if Medicaid state plan services and STAR+PLUS HCBS program services would pose a risk to the individual’s health, safety or welfare.

For applicants and members transferring service areas (SAs), the losing SA MCO must inform the gaining SA MCO of the Medically Fragile group or GR funds process status. 

5100, Initial Referrals for Medically Fragile or GR

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must complete the following activities within five business days of receipt of an approved case assignment from Utilization Review (UR) staff for the Medically Fragile group or General Revenue (GR) funds process:

  • confirm the applicant meets all eligibility criteria for the STAR+PLUS Home and Community Based Services (HCBS) program with the allowance of the individual service plan (ISP) exceeding the cost limit;
  • manually or electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF);
  • upload Form H2065-D to the MCOHub, if manually generated;
  • mail Form H2065-D to the member;
  • for Medical Assistance Only (MAO) members, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • email Enrollment Resolution Services (ERS) Unit staff the following information:
    • an email subject line that reads STAR+PLUS HCBS Enrollment for XX [member’s first and last name initials];
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request: ILR, MFP or upgrade enrollment;
    • effective date of enrollment;
    • Form H2065-D as an attachment;
  • 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 record.

5200, Reassessment for Medically Fragile or GR

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must complete the following activities within five business days of receipt of an approved case assignment from Utilization Review (UR) staff for the Medically Fragile group or General Revenue (GR) funds process:

  • confirm the member continues to meet all eligibility criteria for the STAR+PLUS Home and Community Based Services (HCBS) program with the allowance of the individual service plan (ISP) exceeding the cost limit;
  • electronically generate Form H2065-D, Notification of Managed Care Program Services (PDF), in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
  • mail Form H2065-D to the member;
  • 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 record.

5300, Denials & Terminations for Medically Fragile or GR

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must complete the following activities for applicants within two business days of receipt of a denied case assignment for the Medically Fragile group or General Revenue (GR) funds process:

  • manually generate Form H2065-D, Notification of Managed Care Program Services (PDF), using the exceeds the individual service plan (ISP) cost limit denial reason;
  • mail Form H2065-D to the applicant;
  • upload Form H2065-D to the MCOHub;
  • for medical assistance only (MAO) applicants, fax Form H1746-A, MEPD Referral Cover Sheet (PDF), and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • document and close the CSIL record, if applicable;
  • invalidate the ISP in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP), if applicable;
  • upload 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 for members within two business days of receipt of a denied case assignment for the Medically Fragile group or GR funds process:

  • manually generate Form H2065-D using the exceeds the ISP cost limit denial reason;
  • mail Form H2065-D to the member;
  • upload Form H2065-D to the MCOHub;
  • terminate the ISP in the TMHP LTCOP using an end-date that aligns with the termination effective date;
  • verify the following service group (SG) 19 records in Service Authorization System Online (SASO) are closed to align with the date of termination:
    • Authorizing Agent;
    • Enrollment;
    • Service Plan;
    • Service Authorization;
  • upload applicable documents to the HEART case record; and
  • document the HEART case record.

PSU staff must complete the following activities within two business days after the termination effective date if the member has not requested a fair hearing:

  • for MAO members, fax Form H1746-A and Form H2065-D to the MEPD specialist;
  • for MAO members, email ERS Unit staff the following information:
    • an email subject line that reads: STAR+PLUS HCBS Termination for XX [first letter of the member’s first and last name];
    • the member’s name;
    • Medicaid ID number;
    • type of request: STAR+PLUS Home and Community Based Services (HCBS) program eligibility termination;
    • ISP end date, if applicable;
    • effective date of termination, if applicable;
    • Form H2065-D;
  • upload applicable documents to the HEART case record; and
  • document and close the HEART case record.

The managed care organization (MCO) will not be able to modify the ISP to make it under the cost limit for an applicant or member who was attempting to pursue the Medically Fragile group or GR funds process, unless the applicant or member experiences a change in medical condition.

PSU staff must follow all other existing policies and procedures for processing a STAR+PLUS HCBS program denial or termination.

PSU staff are not required to notify the PSU supervisor or Utilization Review (UR) Unit staff if Medically Fragile group member is denied for reasons not related to clinical criteria. UR staff monitor the Texas Integrated Eligibility Redesign System (TIERS) monthly to determine if a Medically Fragile group member has been denied for reasons not related to clinical criteria.

5400, Fair Hearings for Medically Fragile or GR

Revision 25-1; Effective Feb. 19, 2025

Program Support Unit (PSU) staff must enter an appeal in Texas Integrated Eligibility Redesign System (TIERS) if a fair hearing request is received from the applicant, member, or authorized representative (AR) for an individual service plan (ISP) that exceeds the cost limit.

PSU staff must use the issue code 88-ISP Over the Cost Cap (Medically Fragile) when the data entry representative (DER) is completing Form 4800-D, Fair Hearing Request Summary, or when PSU staff are creating an appeal in TIERS.

PSU staff must enter the following information in TIERS when a fair hearing request for a Medically Fragile group case is received:

  • Office of Medical Director (OMD) staff as the Agency Representative;
  • OMD Unit staff supervisor as the Agency Supervisor;
  • Managed care organization (MCO) representative and MCO supervisor as the Agency Witness; and
  • PSU staff and PSU supervisor as the Observer.
  • MCO representative as the Agency Representative;
  • MCO supervisor as the Agency Supervisor;
  • no Agency Witness is entered; and
  • PSU staff and PSU supervisor as the Observer.

PSU staff must enter the following information in TIERS when any other fair hearing request is received for an ISP more than the cost limit, including cases reviewed for the general revenue (GR) funds process:

  • MCO representative as the Agency Representative;
  • MCO supervisor as the Agency Supervisor;
  • no Agency Witness is entered; and
  • PSU staff and PSU supervisor as the Observer. 

PSU staff must not put an applicant or member name back on the STAR+PLUS Home and Community Based Services (HCBS) program interest list while a denial related to an ISP exceeding the cost limit for the Medically Fragile group or GR funds process is in the state fair hearing process.

PSU staff must take appropriate action to certify or deny the case once the state fair hearing decision is rendered. The applicant or member may choose to be added back to the STAR+PLUS HCBS program interest list if the denial is sustained.