Revision 18-0; Effective September 4, 2018

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

3510 Money Follows the Person and Managed Care

Revision 18-0; Effective September 4, 2018

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

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

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

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

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

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

3511 Money Follows the Person Procedure

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

3512 MFP Applications Pending Due to Delay in NF Discharge

Revision 18-0; Effective September 4, 2018

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

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

Examples:

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

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

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

Revision 23-2; Effective May 15, 2023

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

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

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

3514 STAR+PLUS Individual Residing in a Nursing Facility

Revision 22-3; Effective Sept. 27, 2022

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

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

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

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

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

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

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

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

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

Revision 24-2; Effective May 21, 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Revision 22-3; Effective Sept. 27, 2022

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Revision 23-4; Effective Dec. 7, 2023

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

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

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

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

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

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

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

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

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

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

3520 Money Follows the Person Demonstration

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

3521 Money Follows the Person Demonstration Introduction

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

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

3522 Screening Criteria for Money Follows the Person Demonstration Eligibility

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

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

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

3522.1 Screening for 60-Day Qualifying Institutional Stay

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

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

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

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

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

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

3522.2 MCO Reporting of 60-Day Qualifying Institutional Stay

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

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

3523 Enrollment in Money Follows the Person Demonstration

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

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

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

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

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

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

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

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

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

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

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

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

3530 High or Complex Needs Members

Revision 18-0; Effective September 4, 2018

3531 Designation of High Needs Members

Revision 18-0; Effective September 4, 2018

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

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

CSHCN means a child (or children) who:

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

MSHCN includes a CSHCN and any adult member who:

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

3532 Determination of High Needs Status for Ongoing Members

Revision 18-0; Effective September 4, 2018

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

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