3110 Medicaid, Medicare and Dual-Eligibles

Revision 18-2; Effective September 3, 2018

3111 Dual-Eligible Members

Revision 19-1; Effective June 3, 2019

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

STAR+PLUS Medicaid-only members are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These members receive all covered services, both acute care and long-term services and supports (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.

For members participating in the Texas Integrated Dual Demonstration, STAR+PLUS Medicare-Medicaid Plans (MMPs) are responsible for both Medicare and Medicaid services by ensuring a single point of accountability for the delivery, coordination, and management of Medicare and Medicaid services.

3112 Medicaid Eligibility

Revision 19-1; Effective June 3, 2019

At the time of the initial application for the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must obtain information on the applicant's Medicaid and/or financial status. PSU staff must also obtain verification of the applicant's current eligibility for an appropriate type Medicaid program through the Texas Integrated Eligibility Redesign System (TIERS). If there is no existing acceptable coverage type, PSU staff initiate the Medicaid financial eligibility determination process.

Refer to 3114, Applicants with Medicaid Eligibility, for Medicaid programs appropriate for STAR+PLUS HCBS program financial eligibility status.

Medicaid eligibility may have already been determined and must be used unless there have been changes in the applicant's financial situation. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200.

Note: The completion or signing of an application for an applicant or member does not automatically authorize a person to receive protected health information from PSU staff or the managed care organization (MCO) regarding that applicant or member. See 2119, Personal Representatives, for individuals who may receive or authorize the release of an applicant's or member's individually identifiable health information under Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

3113 Transmittal of Form H1200 or Form H1200-EZ

Revision 18-2; Effective September 3, 2018

When transmitting Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, to Medicaid for the Elderly and People with Disabilities (MEPD), Program Support Unit (PSU) staff fax Form H1200 or Form H1200-EZ to MEPD. Texas Health and Human Services Commission (HHSC) staff retain the original Form H1200 or Form H1200-EZ with the applicant's valid signature in the case record. The original form must be kept for three years after the case is denied or closed. Staff must also retain a copy of the successful fax transmittal confirmation in the case record.

If HHSC staff are co-housed with MEPD, the original Form H1200 or Form H1200-EZ is hand-delivered to the MEPD specialist and HHSC staff retain a copy of the form in the case record. If unusual circumstances exist in which the original must be mailed to the MEPD specialist after faxing, HHSC staff must mark "DUPLICATE" on the top of the form and retain a copy of the form in the case record. Scanning Form H1200 or Form H1200-EZ and sending by electronic mail is prohibited.

3114 Applicants with Medicaid Eligibility

Revision 18-2; Effective September 3, 2018

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

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

Applicants who receive Supplemental Security Income (SSI) are financially eligible for Medicaid and do not require a financial determination; the Social Security Administration (SSA) has already made this determination.

Applicants receiving services through Community Attendant Services (TIERS TP14) are not automatically eligible for the STAR+PLUS HCBS program. MEPD specialists must be consulted for these applicants. Applicants who currently have Form H1200, Application for Assistance – Your Texas Benefits, on file with the Texas Health and Human Services Commission (HHSC) may not need to complete a new Form H1200.

3115 Applicants Without Medicaid Eligibility

Revision 19-1; Effective June 3, 2019

The Code of Federal Regulations (CFR), Section 42 CFR 431.10, specifies that Medicaid eligibility must be determined by a single state agency. The Texas State Plan designates the Texas Health and Human Services Commission (HHSC) as the sole agency with the authority to make eligibility determinations for medical assistance only (MAO) cases.

Financial eligibility for non-Supplemental Security Income (SSI) STAR+PLUS Home and Community Based Services (HCBS) program is determined exclusively by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. Program Support Unit (PSU) staff must not:

• screen applicants from referral to MEPD due to apparent financial ineligibility; or
• deny applications or recertifications based on financial eligibility criteria unless notified by the MEPD specialist of financial ineligibility.

If the applicant's individual income exceeds the SSI federal benefit rate (FBR) per month, the applicant applies for Medicaid through HHSC by completing Form H1200, Application for Assistance – Your Texas Benefits, for MAO. If the combined income of the applicant and the spouse exceeds the SSI FBR for a couple, the applicant may apply for MAO with HHSC. Refer to Appendix VIII, Monthly Income/Resource Limits, for the current SSI FBR.

3116 Monthly Income Below the Supplemental Security Income Standard Payment

Revision 19-1; Effective June 3, 2019

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

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

3117 Coordination with Medicaid for the Elderly and People with Disabilities Staff

Revision 18-2; Effective September 3, 2018

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

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

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

• Form H1200, Application for Assistance – Your Texas Benefits;
• Form H1200-A, Medical Assistance Only (MAO) Recertification; or
• Form H1010, Texas Works Application for Assistance – Your Texas Benefits

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

PSU staff must also send an email to the MEPD specialist that includes the following information:

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

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

Identification of MAO Coverage-Type Medicaid

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

An application form is not required for members receiving Supplemental Security Income (SSI).

If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission's (HHSC’s) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDU staff to make a disability determination, DDU staff require Form H3034, Disability Determination Socio-Economic Report, Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, the MEPD specialist is notified.

3117.1 Income and Resource Verifications for Medicaid for the Elderly and People with Disabilities

Revision 19-1; Effective June 3, 2019

Any information, including information on third-party insurance, obtained by Program Support Unit (PSU) staff must be shared with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to prevent the applicant or member from having to provide the information twice. Any information obtained by managed care organization (MCO) staff must be immediately forwarded to PSU staff so it can be passed on to the MEPD specialist.

Inform medical assistance only (MAO) applicants of the importance of providing the most complete packet possible to the MEPD specialist. Explain that failure to submit the required documentation to the MEPD specialist could delay completion of the application or cause the application to be denied.

Ensuring the following items are included greatly facilitates the financial eligibility process:

• Bank accounts – bank name, account number, balance and account verification (for example, a copy of the bank statement)
• Award letters showing the amount and frequency of income payments
• Life insurance policy – company name, policy number, face value or a copy of the policy
• A signed and dated Form H0003, Agreement to Release Your Facts
• Confirmation that Medicaid Estate Recovery Program information was shared with the applicant by checking the appropriate box on Form H1746-A, MEPD Referral Cover Sheet
• Preneed funeral plans – name of the company, policy or plan number and a copy of the preneed agreement
• Correct and up-to-date telephone numbers
• Power of Attorney or Guardianship – copy of the legal document

PSU staff must inform the MEPD specialist of the request for the STAR+PLUS Home and Community Based Services (HCBS) program, according to regional procedures. PSU staff should obtain a copy of the most recent Form H1200, Application for Assistance – Your Texas Benefits, for those applicants or members already on an appropriate type of Medicaid program. Form H1200 is not required for members receiving Supplemental Security Income (SSI).

If a STAR+PLUS HCBS program applicant's or member's application for SSI disability has been pending more than 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Services (DDS) staff may determine disability, pending the Social Security Administration (SSA) determination. The SSI decision must be adopted when it is received from SSA. In order for DDS staff to make a disability determination, DDS staff require Form H3034, Disability Determination Socio-Economic Report, Form H3035, Medical Information Release/Disability Determination, and a copy of the Medical Necessity and Level of Care (MN/LOC) Assessment. If additional records are necessary, the MEPD specialist will be notified.

3117.2 MAO Applicants Not Previously Certified in TIERS

Revision 18-2; Effective September 3, 2018

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

Once staff determine applicants being referred to MEPD for a financial determination do not have any prior certifications in TIERS, Form H1746-A, MEPD Referral Cover Sheet, and Form H1746-B, Batch Cover Sheet, must be used to send Form H1200, Application for Assistance – Your Texas Benefits, Form H1200-EZ, Application for Assistance – Aged and Disabled, or Form H1010, Texas Works Application for Assistance – Your Texas Benefits, to the Midland Document Processing Center (DPC). Form H1746-B must be attached to the top of each batch containing more than one Form H1746-A being sent to DPC.

3117.3 Unsigned Applications

Revision 18-2; Effective September 3, 2018

Unsigned applications received by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist are returned to the sender. Texas Health and Human Services Commission (HHSC) staff must ensure applications are signed prior to referring to the MEPD specialist; if not, HHSC staff are required to obtain signatures when unsigned applications are returned.

The application forms are:

• Form H1200, Application for Assistance – Your Texas Benefits;
• Form H1200-EZ, Application for Assistance – Aged and Disabled;
• Form H1200-A, Medical Assistance Only (MAO) Recertification; and
• Form H1010 – Texas Works Application for Assistance – Your Texas Benefits.

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

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

3117.4 Medicaid Eligibility Decisions Pending Past the Program Due Date

Revision 19-1; Effective June 3, 2019

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

For other case actions (for example, program transfers), the MEPD specialist may require time to verify income and resources. This is especially true if the previous case was community-based or included an individual declaration of income/resources. Program Support Unit (PSU) staff may contact MEPD once they have been pending more than 45 days.

3120 Other Available Services

Revision 18-2; Effective September 3, 2018

3121 Prescription Drugs

Revision 22-1; Effective March 1, 2022

STAR+PLUS managed care organizations (MCOs) are responsible for providing outpatient drugs, biological products, certain limited home health supplies (LHHS), and vitamins and minerals as identified on the HHSC drug formulary. Members who are Medicaid only will receive their prescription drug benefits through Medicaid. Members who are enrolled in Medicare Part D drug coverage will receive their prescription drug benefits through Medicare with some exceptions. MCOs must also supplement Medicare coverage for STAR+PLUS Dual Eligible Members by providing services, supplies, and outpatient drugs and biologicals that are available under the Texas Medicaid program.

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

Pharmacy staff also have various sources and methods that may be used to verify a person’s enrollment status, pharmacy benefits, participation in managed care and Medicare coverage. See the Medicaid Formulary for all covered drugs. This formulary applies only to members who will receive their prescription drug benefit solely through Medicaid.

STAR+PLUS Prescription Drug Coverage and Medicare Part D

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

Federal law prohibits the use of STAR+PLUS program funds for Medicare Part D prescriptions, copayments and costs. STAR+PLUS program funds may be used for prescriptions, copayments and costs to the extent covered by Medicare Part D or to the extent covered by private insurance if the member chooses private insurance rather than participation in Medicare Part D.

The MCO must inform members of the following information regarding the impact of the Medicare Part D program:

• If a member is considered dual-eligible (receiving both Medicare and Medicaid), the member obtains prescriptions first through Medicare Part D or, for certain prescribed drugs excluded from Medicare Part D, through the Vendor Drug Program (VDP).
• Drug coverage through Medicare is limited to each drug plan's formulary and may not cover all prescribed medications required for the member. Medicaid will pay for some drugs excluded from Medicare Part D coverage. Texas Medicaid will pay for wrap-around drugs/products for dual-eligible people after commercial insurance has been billed or if there is no commercial insurance on file. These drugs include nonprescription (over-the-counter) medications, some products used in symptomatic relief of cough and colds, and some prescription vitamins and mineral products.
• Medicaid will pay for a limited set of home health supply products.
• Members who participate in Medicare Part D are responsible for purchasing any medications and copayments for medications not covered through Medicare Part D or the Medicaid VDP.
• Some members may choose to disenroll or opt out of their Medicare Part D plan, meaning the member has chosen not to participate in the Medicare Part D plan. Medicaid is not liable for the member’s prescription drug coverage if the member opts out of enrolling in a Part D plan.
• Members eligible for both Medicare and Medicaid can receive assistance with prescription costs through the Low Income Subsidy program through Medicare. These members pay little or no premiums and no deductibles. Drug copayment amounts could range from $1 to $5.

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

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

Refer to 3123, Incurred Medical Expenses.

3122 Reserved for Future Use

Revision 22-1; Effective March 1, 2022

3123 Incurred Medical Expenses

Revision 18-2; Effective September 3, 2018

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

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

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

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

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

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

3124 Medical Transportation

Revision 18-2; Effective September 3, 2018

STAR+PLUS Home and Community Based Services (HCBS) program members, as recipients of Medicaid, are eligible to use the Medicaid medical transportation system for Medicaid-covered medical appointments. The Medicaid medical transportation system is accessed by calling the local agency whose number is available from the Texas Health and Human Services Commission (HHSC). Day Activity and Health Services (DAHS) providers, adult foster care (AFC) and assisted living (AL) providers are responsible for scheduling transportation for the residents.

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

There may be questions about eligibility for participants who are living in an AFC/ALF. In cases of difficulties in scheduling, or questions about eligibility for transportation, participants should contact the managed care organization to intercede on the participant's behalf with the local Medicaid medical transportation system.

3125 Community Care Services Eligibility

Revision 21-1; Effective May 1, 2021

STAR+PLUS members who are not receiving STAR+PLUS Home and Community Based Services (HCBS) waiver services may be eligible to receive fee-for-service Community Care Services Eligibility (CCSE) services from the Texas Health and Human Services Commission (HHSC) if they meet program requirements. CCSE services include:

• adult foster care;
• residential care;
• emergency response services (ERS);
• home-delivered meals; and
• special services to persons with disabilities.

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

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

STAR+PLUS members are not eligible to receive the following CCSE services from HHSC:

• day activity and health services (DAHS);
• community attendant services (CAS);
• primary home care (PHC); and
• assisted living (AL).

If an individual requests CCSE services, CCSE staff will add the individual to any applicable Medicaid waiver interest lists at the time of the request to protect the date and time of the request. Prior to processing an application, CCSE staff must verify the MCO service array does not include a service equivalent to the CCSE Title XX service requested. CCSE staff may view the STAR+PLUS Comparison Charts and value-added services (VAS) on the HHSC website at  https://hhs.texas.gov/services/health/medicaid-and-chip/programs/starplus/comparison-charts.

VAS offered by an MCO are extra services approved by HHSC. Value-added services will vary by MCO. Once released from the CCSE Title XX interest list, the CCSE staff verifies the applicant’s MCO does not offer an equivalent service as a VAS and proceeds with the eligibility determination for the requested CCSE Title XX service.

CCSE staff should ask the member if they have requested the service from the MCO if the requested service is not a VAS but is part of the MCO's service array. If the answer to that question is:

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

Once released from the interest list, CCSE staff may proceed to determine eligibility. CCSE staff should only process applications for individuals who are enrolled in STAR+PLUS only if they meet the criteria outlined above. CCSE staff must not authorize CCSE Title XX services for anyone receiving the STAR+PLUS HCBS program. The STAR+PLUS HCBS program is required to provide all of the services (excluding hospice services) needed to enable the member to live safely in the community. STAR+PLUS HCBS program members requesting additional services must be referred to their service coordinator.

3126 Health Insurance Premium Payment Program

Revision 21-1; Effective May 1, 2021

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

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

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