1100, STAR+PLUS Program Overview

Revision 19-13; Effective November 5, 2019

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

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

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

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

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

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

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

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

1110 Legal Basis

Revision 19-13; Effective November 5, 2019

Statutory basis for the STAR+PLUS program:

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

1120 Values

Revision 18-0; Effective September 4, 2018

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

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

1130 Mission Statement

Revision 19-13; Effective November 5, 2019

The mission of Texas Health and Human Services Commission (HHSC) is to provide individually appropriate Medicaid managed care services to adults to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR+PLUS program is established to:

  • coordinate care across service arrays;
  • improve quality, continuity and customization of care;
  • improve access to care and provide person-centered health homes;
  • improve ease of program participation for members, managed care organizations (MCOs) and providers;
  • improve provider collaboration and integration of different services;
  • improve member outcomes to the greatest extent achievable;
  • foster program innovation; and
  • achieve cost efficiency and cost containment.

1140 STAR+PLUS HCBS Program

Revision 19-13; Effective November 5, 2019

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

1150 STAR+PLUS HCBS Program Goal

Revision 19-13; Effective November 5, 2019

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

The STAR+PLUS HCBS program accomplishes this goal by:

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

1200, STAR+PLUS Program Eligibility

Revision 19-13; Effective November 5, 2019

An individual becomes eligible to be assessed for STAR+PLUS Home and Community Based Services (HCBS) program services when their name reaches the top of the STAR+PLUS HCBS program interest list. An individual is placed on the interest list by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if he or she is already enrolled in STAR+PLUS. For medical assistance only (MAO) individuals, once their name reaches the top of the interest list, the individual selects an MCO who begins the STAR+PLUS HCBS program eligibility determination process. For individuals currently receiving Medicaid and who are already enrolled with an MCO, they may be able to bypass the interest list through the upgrade process.

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

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

  • be 21 years or older;
  • have full Medicaid financial eligibility;
  • be a U.S. citizen;
  • be a resident of Texas;
  • have an approved medical necessity (MN) for an NF level of care (LOC);
  • have an individual service plan (ISP) with services under the established cost limit;
  • have an unmet need for at least one STAR+PLUS HCBS program service; and
  • be living in an appropriate living situation.

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

1210 Age

Revision 19-13; Effective November 5, 2019

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

1220 Medicaid Financial Eligibility

Revision 19-13; Effective November 5, 2019

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

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

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

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

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

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

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

1230 U.S. Citizenship

Revision 19-13; Effective November 5, 2019

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long-term services and supports (LTSS) members whose financial eligibility is based on a determination from a Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Verification of citizenship and identity for eligibility purposes is a one-time activity conducted by an MEPD specialist, as documented in the MEPD HandbookChapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by an MEPD specialist, verification is no longer required even after a break in eligibility. Therefore, applicants who are active Medicaid, Medicare or Supplemental Security Income (SSI) recipients do not require citizenship verification since verification occurred upon entry in those programs.

1240 Texas Residency

Revision 19-13; Effective November 5, 2019

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

1250 Medical Necessity Determination

Revision 19-13; Effective November 5, 2019

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

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

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

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

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

1260 Individual Service Plan Cost Limit

Revision 19-13; Effective November 5, 2019

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

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

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

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

Revision 19-13; Effective November 5, 2019

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

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

1280 Appropriate Living Arrangement

Revision 19-13; Effective November 5, 2019

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

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

1300, STAR+PLUS Services and Service Delivery Options

Revision 19-13; Effective November 5, 2019

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

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

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

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

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

 

1310 Program Services

Revision 19-13; Effective November 5, 2019

 

1311 Services Available Under STAR+PLUS

Revision 19-13; Effective November 5, 2019

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

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

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

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

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

 

1312 Long Term Services and Supports

Revision 19-13; Effective November 5, 2019

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

 

1320 Services Available to STAR+PLUS Members

Revision 19-13; Effective November 5, 2019

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

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

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

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

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

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

 

1330 Acute Care Services Included Under the MCO Capitation Payment

Revision 19-13; Effective November 5, 2019

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

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

 

1340 Long Term Services and Support Listing

Revision 19-13; Effective November 5, 2019

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

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

 

1350 Services Available to STAR+PLUS HCBS Program Members

Revision 19-13; Effective November 5, 2019

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

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

1400, MCO Service Coordination

Revision 19-13; Effective November 5, 2019

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

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

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

1500, Disclosure of Information

1510 Confidential Nature of Medical Information - HIPAA

Revision 19-13; Effective November 5, 2019

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of protected health information (PHI). PHI is information that identifies or could be used to identify an applicant or member and that relates to the:

  • past, present or future physical, mental or behavioral health or condition of the applicant or member;
  • provision of health care to the applicant or member; or
  • past, present or future payment for the provision of health care to the applicant or member.

PHI includes an individual's date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number and demographic data.

1511 Confidential Nature of a Case Record

Revision 19-13; Effective November 5, 2019
 
Information collected in determining initial or continuing eligibility is confidential. The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about, or does not specifically identify an applicant or member.

An applicant, member or authorized representative (AR) may review all information in the case record and in HHSC or MCO handbooks that contributed to the decision about eligibility.

1512 Custody of Records

Revision 19-13; Effective November 5, 2019

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

Reasonable diligence for employees responsible for records includes keeping records:

  • in a locked office when the building is closed;
  • properly filed during office hours; and
  • in the office at all times, except when authorized to remove or transfer them.

1520 Responsible Party to Authorize Disclosure

Revision 19-13; Effective November 5, 2019

 

1520.1 Authorized Representative

Revision 19-13; Effective November 5, 2019

Only the member's authorized representative (AR) can exercise the applicant’s or member's rights with respect to protected health information (PHI). Therefore, only an applicant or member's AR may authorize the use or disclosure of PHI or obtain PHI on behalf of an applicant or member. Exception: Texas Health and Human Services Commission (HHSC) is not required to disclose the information to the AR if the applicant or member is subjected to domestic violence, abuse or neglect by the AR. Consult the HHSC Office of Chief Counsel, as described in Section 1530, Information May Be Disclosed, if it is believed that health information should not be released to the AR.

Note: A responsible party is not automatically an AR.

1520.2 Unemancipated Minors

Revision 19-13; Effective November 5, 2019

A parent is the authorized representative (AR) for a minor child except when:

  • the minor child can consent to medical treatment. Under these circumstances, do not disclose to a parent information about the medical treatment to which the minor child can consent. A minor child can consent to medical treatment when the:
    • minor is on active duty with the U.S. military;
    • minor is age 16 or older, lives separately from the parents and manages his or her own financial affairs;
    • consent involves diagnosis and treatment of disease that must be reported to the local health officer or the Texas Department of State Health Services (DSHS);
    • minor is unmarried and pregnant and the treatment (other than abortion) relates to the pregnancy;
    • minor is age 16 years or older and the consent involves examination and treatment for drug or chemical addiction, dependency or use at a treatment facility licensed by DSHS;
    • consent involves examination and treatment for drug or chemical addiction, dependency or use by a physician or counselor at a location other than a treatment facility licensed by the state of Texas;
    • minor is unmarried, is the parent of a child, has actual custody of the child and consents to treatment for the child; or
    • consent involves suicide prevention or sexual, physical or emotional abuse.
  • a court is making health care decisions for the minor child or has given the authority to make health care decisions for the minor child to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about health care decisions not made by the parent.

1520.3 Adults and Emancipated Minors

Revision 19-13; Effective November 5, 2019

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

  • person the applicant or member has appointed under a medical power of attorney, a durable power of attorney with the authority to make health care decisions, or a power of attorney with the authority to make health care decisions;
  • court appointed guardian for the applicant or member; or
  • person designated by law to make health care decisions when the applicant or member is in a hospital or nursing facility (NF) and is incapacitated or mentally or physically incapable of communication.

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

1520.4 Deceased Applicant or Member

Revision 19-13; Effective November 5, 2019

The authorized representative (AR) for a deceased applicant or member is an executor, administrator or other person with authority to act on behalf of the applicant, member or the member's estate. These include:

  • an executor, including an independent executor;
  • an administrator, including a temporary administrator;
  • a surviving spouse;
  • a child;
  • a parent; and
  • an heir.

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

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

Revision 19-13; Effective November 5, 2019

 

1521.1 Phone Communication

Revision 23-3; Effective Aug. 21, 2023

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

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

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

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

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

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

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

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

1521.2 In-Person Communication

Revision 19-13; Effective November 5, 2019

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

  • U.S. passport;
  • Texas Department of Public Safety (DPS) ID card;
  • DPS driver license;
  • DPS Texas Election Identification Certificate;
  • DPS handgun license;
  • U.S. military ID card containing the photograph;
  • U.S. citizenship certificate containing the person’s photograph;
  • state agency employee badge;
  • Social Security number (SSN) card;
  • Medicaid ID card;
  • birth certificate or birth record;
  • hospital record;
  • work or school ID card;
  • voter registration card; and/or
  • wage stub.

Establish the identity of other HHSC or MCO staff, federal agency staff, research staff or contractors by examining at least one source such as:

  • employee badge; or
  • government-issued identification card with a photograph.

Identify the need for other HHSC or MCO staff, federal staff, research staff or contractors to access protected health information (PHI) through one of the following:

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

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

1521.3 Electronic Mail Communication

Revision 19-13; Effective November 5, 2019

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

  • If PSU staff can answer the inquiry without supplying PHI, remove any PHI in the original request, notify the sender that this is not a secure method of transmission for PHI, and respond to the sender appropriately; or
  • If the answer to the inquiry requires the inclusion of PHI, remove any PHI in the original request, notify the sender that this is not a secure method of transmission of PHI, and respond to the sender that he or she must submit their request in writing by mail or fax.

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

PSU staff may share PHI by email with Medicaid for the Elderly and People with Disabilities (MEPD), Texas Medicaid & Healthcare Partnership (TMHP), managed care organization (MCO) the applicant or member is enrolled with, and other Texas Health and Human Services Commission (HHSC) staff for work-related purposes, but only if the email:

  • is sent to a verified email address;
  • is sent as an encrypted message;
  • does not contain PHI in the email’s subject line; and
  • contains this disclaimer: "Confidential: This transmission is confidential and intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient, you are notified that any review, retention, disclosure, copying, distribution, or the taking of any other action relevant to the contents of this transmission are strictly prohibited. If you received this transmission in error, please return to sender."

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

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

1530 Information That May Be Disclosed

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

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

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

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

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

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

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

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

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

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

PSU staff may use the following: 

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

A valid Form H1826 is:

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

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

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

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

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

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

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

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

1531 Verification and Documentation of Disclosure

Revision 19-13; Effective November 5, 2019

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

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

  • U.S. passport;
  • Texas Department of Public Safety (DPS) ID card;
  • DPS driver license;
  • DPS Texas Education Identification Certificate;
  • DPS handgun license;
  • U.S. military ID card containing the person’s photograph;
  • U.S. citizenship certificate containing the person’s photograph;
  • state agency employee badge;
  • Social Security number (SSN) card;
  • Medicaid ID card;
  • birth certificate or birth record;
  • hospital record;
  • work or school ID card;
  • voter registration card; and/or
  • wage stubs.

When disclosing PHI, PSU staff must document transactions and maintain documentation in the member's Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record pertaining to how the identity of the person was verified and the method of how the information was released to the individual. Approved methods of releasing PHI include providing the requestor copies of documentation in person, by fax or by mail.

1532 Communication with the Applicant or Member

Revision 19-13; Effective November 5, 2019

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

The applicant, member or AR must specify in writing the alternate mailing address or means of contact and include a statement that using the home mailing address or normal means of contact could endanger the applicant or member.

1533 Confidential Information on Notifications

Revision 19-13; Effective November 5, 2019

The Texas Health and Human Services Commission (HHSC) is committed to protecting all protected health information (PHI) supplied by the applicant, member or authorized representative (AR) during the eligibility determination process. This includes inclusion of PHI by HHSC staff to third parties who receive a copy of a notification of eligibility form.

HHSC staff must not include PHI on the eligibility notice shared with the service provider or another third party.

Examples:

  • Notification is received from Medicaid for the Elderly and People with Disabilities (MEPD) that the member has lost Medicaid because the member’s income of $2,892 exceeds the eligibility limit of $2,313. It is a violation of confidentiality to record on Form H2065-D, Notification of Managed Care Program Services, “Your income of $2,892 exceeds the eligibility limit of $2,313.” The comment should simply state, “You are no longer eligible for Medicaid.”
  • Another applicant is being denied STAR+PLUS Home and Community Based Services (HCBS) program services because the presence of weapons in the member’s home presents a hazard to service providers. It is a violation of confidentiality to record on Form H2065-D, "The presence of weapons in your home presents a hazard to service providers." The comment should simply state, "Your services are being denied due to hazardous conditions in your home."

In the examples above, revealing specifics of the applicant’s or member’s income or the condition of the home environment is a violation of the member’s right to confidentiality. In all cases, HHSC staff must assess any information provided by the applicant or member to determine if its release would be a confidentiality violation.

1534 PSU Communication with the MCOs

Revision 19-13; Effective November 5, 2019

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

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

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

1535 Applicant or Member Correction of Information

Revision 19-13; Effective November 5, 2019

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

A request for correction must be in writing and:

  • identify the applicant or member asking for the correction;
  • identify the disputed information about the applicant or member;
  • state why the information is wrong;
  • include any proof that shows the information is wrong;
  • state what correction is requested; and
  • include a return address, telephone number or email address at which HHSC or the MCO can contact the applicant or member.

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

Notify the applicant, member or AR in writing within 60 days (using agency letterhead) the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC or the MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

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

Note: Do not follow above procedures when the accuracy of information provided by a member or AR is determined by another review process, such as a:

  • fair hearing;
  • civil rights hearing; or
  • other appeal process.

The decision in the above review processes is the decision on the request to correct information.

1536 Disposal of Records

Revision 19-13; Effective November 5, 2019

To dispose of documents with member-specific information, Texas Health and Human Services Commission (HHSC) staff must follow established procedures for destruction of confidential data as described in the Health and Human Services (HHS) Computer Usage and Information Security Training.

1600, Member Rights and Responsibilities

Revision 19-13; Effective November 5, 2019

Member rights and responsibilities are included in the Member Handbook. The required critical elements for member handbooks can be found at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the applicant, member, or authorized representative (AR) at application. This document is shared in the language preference expressed by the applicant or member.

In addition, an applicant, member or AR may refer to the Title 1 Texas Administrative Code (TAC) Part 15, §353 Subchapter C, Member Bill of Rights and Responsibilities, to view the full list of member rights and responsibilities.

1700, Notification Requirements

1710 PSU Staff Notification Requirements for Applicants and Members

Revision 22-1; Effective January 31, 2022

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

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

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

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

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

1720 PSU Staff Notification Requirements for MCOs

Revision 19-13; Effective November 5, 2019

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

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

Revision 19-13; Effective November 5, 2019

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

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

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

1740 PSU Staff Notification Requirements for Enrollment Resolution Services Unit

Revision 19-13; Effective November 5, 2019

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

The email to the ERS Unit mailbox must include:

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

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

Revision 19-13; Effective November 5, 2019

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

The email to the MCCO Unit mailbox must include:

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

1760 MCO Notification Requirements for Applicants and Members

Revision 19-13; Effective November 5, 2019

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

1770 MCO Notification Requirements for PSU Staff

Revision 21-10; Effective October 25, 2021

The managed care organization (MCO) must use Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section B, and Form H2067-MC, Managed Care Programs Communication, for all communications sent to Program Support Unit (PSU) staff, as applicable. The MCO must upload Form H3676, Section B, or Form H2067-MC to TxMedCentral. PSU staff will retrieve all MCO postings daily from TxMedCentral.

The MCO has 45 days from the date PSU staff uploaded Form H3676, Section A, to TxMedCentral, to upload Form H3676, Section B, for individuals or applicants. The MCO has between one business day and 14 days to upload Form H2067-MC, depending on the situation for an individual, applicant or member. Specific MCO time frames for Form H2067-MC are defined throughout this handbook.

1800, PSU Online Database Resources

Revision 19-13; Effective November 5, 2019

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

1820 Community Services Interest List

Revision 19-13; Effective November 5, 2019

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

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

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

1830 Health and Human Services Commission Benefits Portal

Revision 19-13; Effective November 5, 2019

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

PSU staff use the HHSC Benefits portal to:

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

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

Revision 19-13; Effective November 5, 2019

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

PSU staff use HEART to:

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

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

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

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

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

1850 Service Authorization System Online

Revision 19-13; Effective November 5, 2019

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

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

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

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

1860 Texas Integrated Eligibility Redesign System

Revision 19-13; Effective November 5, 2019

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

1870 Texas Medicaid & Healthcare Partnership Long Term Care Online Portal

Revision 19-13; Effective November 5, 2019

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

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

1880 TxMedCentral

Revision 19-13; Effective November 5, 2019

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

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