3300, Member Service Planning and Authorization
Revision 22-2; Effective September 1, 2022
Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. Except as provided below for members receiving Medically Dependent Children Program (MDCP) services, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). The ISP must be completed within 60 days of completion of the SK-SAI for all subsequent reassessments. The MCO must ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility.
The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs, and member preferences. The ISP must be used to communicate and help align expectations between the member, their legally authorized representative (LAR), the MCO and key service providers.
The STAR Kids Individual Service Plan (SK- ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member and their LAR, on the member's behalf, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The STAR Kids ISP is for:
- documenting findings from the SK-SAI;
- developing a plan for services received through the STAR Kids MCO;
- documenting services received through third party sources, such as 1915(c) waivers operated by the state;
- identifying the member or applicant’s strengths, preferences, support needs and desired outcomes;
- identifying what is important to the member;
- identifying available natural supports available to the member and needed service system supports;
- documenting the individual’s preferences for when and how to receive services;
- identifying any special needs, requests, or considerations the MCO and/or providers should know when supporting the member; and
- documenting the member's unmet needs.
For STAR Kids members receiving MDCP services, the ISP must establish an MDCP service plan that falls within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a copy of the ISP to each member or their LAR following any significant update and no less than annually within five business days of meeting with the member or LAR. The MCO must provide a copy of the ISP to the member's providers and other individuals specified by the member or LAR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language.
The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports (LTSS) no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member's current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member's service coordinator, or a representative of the MCO, must review and update each member's ISP with the member and their LAR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.
3310 Service Planning
Revision 22-2; Effective September 1, 2022
All STAR Kids narrative individual service plans (ISPs) must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:
- A summary document describing the recommended service needs identified through the SK-SAI;
- Covered services currently received;
- Covered services not currently received, but that the member might benefit from;
- A description of non-covered services that could benefit the member;
- Member and family goals and service preferences;
- Natural strengths and supports of the member including helpful family members, community supports or special capabilities;
- A description of roles and responsibilities for the member, their legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the managed care organization (MCO), and the member's school with respect to maintaining and maximizing the health and well-being of the member;
- A plan for coordinating and integrating care between providers and covered and non-covered services;
- Short and long-term goals for the member's health and well-being;
- If applicable, services provided to the member through waiver programs not operated by the MCO or third-party resources, and the sources or providers of those services;
- Plans specifically related to transitioning to adulthood for members age 15 and older; and
- Any additional information to describe strategies to meet service objectives and member goals.
The ISP must be formed by findings from the STAR Kids screening and assessment process, in addition to input from the member, their family and caretakers, providers and any other individual with knowledge and understanding of the member's strengths and service needs who is identified by the member, the member's LAR or the MCO. To the extent possible and applicable, the ISP must also account for school-based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but must not require the member, to provide a copy of the member's Individualized Education Plan (IEP) or the Early Childhood Intervention (ECI) Individualized Family Service Plan (IFSP).
The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week (if applicable), begin/end date, and whether the member has chosen the Consumer Directed Services or Service Responsibility Option, if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by third-party resources, like Medicare or available community services. This form is updated, per the section below, and is maintained in the member's case file.
3311 Updates to the Individual Service Plan
Revision 19-1; Effective September 3, 2019
Each member's individual service plan must be updated at least annually, or sooner for situations outlined in the STAR Kids Contract, Section 8.1.39.1.
3320 Service Planning for Medically Dependent Children Services
Revision 22-3; Effective Dec. 1, 2022
The managed care organization (MCO) service coordinator or nurse assessor must complete Form 2605, Member SK-SAI MDCP Review Signature, for all initial assessments and reassessments of Medically Dependent Children Program applicants and members. The MCO service coordinator must maintain Form 2605 in the member’s case file.
The service coordinator must work with the member or their legally authorized representative (LAR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member's Resource Utilization Group (RUG) value, determined by the STAR Kids Screening and Assessment Instrument (SK-SAI) MDCP module. Cost limits associated with each RUG value are found in Appendix VIII, RUG IPC Cost Limits.
The service coordinator documents these MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week, begin and end date, and if the member has chosen the Agency Option, Consumer Directed Services, or Service Responsibility Option, if applicable. The form must also include a brief rationale such as why the service is needed or requested.
The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the managed care organization (MCO) completes and submits the electronic SK-ISP within 60 days of the initial notification from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic SK-ISP within 60 days following receipt of a response to the SK-SAI submission. The response file from Texas Medicaid & Healthcare Partnership (TMHP) contains the determination of medical necessity and the member's RUG value. The start date for the SK-ISP must be the first day of the next month. If a Medicaid eligibility determination is required, the start date of the SK-ISP is the first day of the month following a determination of Medicaid eligibility. An ISP is valid for one year.
When the member's SK-ISP is complete and within the member's established cost limit, the MCO submits the SK-ISP as Form 2604 to the TMHP Long Term Care (LTC) Online Portal or through a 278 transaction. The MCO must submit the electronic SK-ISP before the start date of the member's ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.
If the member is turning 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member's cost limit. To calculate the prorated cost, the MCO must:
- Step 1: divide the cost limit by the total number of days (365) in a year.
- Step 2: determine the total number of days beginning with the start date of the individual service plan (ISP) and ending the last day of the month of the member's 21st birthday.
- Step 3: multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the ISP period for which the member is eligible.
Example: The member's 21st birthday is July 9, the ISP start date is April 1, and the end date will be July 31. The member's cost limit is $25,000.
- Step 1: $25,000 ÷ 365 days = $68.49 per day
- Step 2: The number of days per month: April = 30, May = 31, June = 30, July = 31, for a total of 122 days
- Step 3: $68.49 × 122 = $8,355.78
$8,355.78 is the prorated cost limit for the individual for the ISP.
3321 Medically Dependent Children Program Individual Service Plan Revision
Revision 22-3; Effective Dec. 1, 2022
A managed care organization (MCO) must generate an amended ISP when a significant change occurs in a member’s condition. The MCO must retain amended ISPs in the MCO’s member case file. If a member or their legally authorized representative (LAR) requests a change to the member's Medically Dependent Children Program (MDCP) service plan, but the member has not experienced a change in condition that affects their Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request in 14 days.
To revise a member's MDCP individual service plan (ISP) when there is no change in the member's RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and Form 2604 – STAR Kids ISP – Tracking Tool with the updated services and a revised begin date as applicable. The MCO maintains the updated SK ISP Forms in the member's file.
3322 Medically Dependent Children Program Individual Service Plan and Budget Revision
Revision 22-2; Effective September 1, 2022
If a member and/or their legally authorized representative (LAR), the member's provider or the managed care organization (MCO) service coordinator notify the MCO about a change in the member's condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the MCO must reassess the member within 14 days and follow the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, to document the RUG change.
Following receipt of a STAR Kids Screening and Assessment Instrument (SK-SAI) response file indicating the member's new RUG, the MCO completes a new STAR Kids individual service plan (SK-ISP) that reflects the member’s/LAR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member's new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the member's case file.
If a member will turn age 21 between the start and end date of the member's ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or transition assistance are provided prior to the member's birthday. If the MCO authorizes adaptive aids, minor home modifications or transition assistance, the MCO remains responsible for payment for those services, including applicable warranties.
3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan
Revision 22-2; Effective September 1, 2022
Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member or their legally authorized representative (LAR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member/LAR chooses to set aside funds, the MCO must document the member’s/LAR's preferences and maintain documentation in the member's case file. A member or LAR may not carry forward funds between ISP periods.
3324 Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services
Revision 22-2; Effective September 1, 2022
As a part of the individual service planning process, the managed care organization (MCO) must establish a Medically Dependent Children Program (MDCP) individual service plan (ISP) that does not exceed the individual’s cost limit linked to the Resource Utilization Group (RUG) value assigned. In rare cases, the member’s condition may require a high utilization of waiver services; the MCO must make best efforts to provide State Plan services where appropriate. If the ISP cost exceeds the RUG cost limit, the MCO submits via email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:
- STAR Kids Screening and Assessment Instrument (SK-SAI);
- STAR Kids Individual Service Plan (SK-ISP) and any Addendums; and
- Medical records (nursing care plan, recent care notes, doctor's orders and nursing notes).
HHSC UR may request a clinical review of the case to consider the use of state General Revenue funds to cover costs exceeding 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit (PSU).
Note: MCOs must not discuss with applicants, legally authorized representatives (LARs) or members, or request use of state General Revenue funds for services above the cost ceiling.
3325 Multiple Medically Dependent Children Program Members in the Same Household
Revision 22-2; Effective September 1, 2022
In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each of those members.
In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member's care is based on their individual service plan (ISP) and all individuals’ needs are met.
Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.
3326 Suspension of Medically Dependent Children Program Services
Revision 18-2; Effective September 3, 2018
A member enrolled in the Medically Dependent Children Program (MDCP), who is also receiving Community First Choice (CFC) and has a medical assistance only (MAO) eligibility for Medicaid, must receive one MDCP service monthly. In the event the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. For members who do not receive CFC and also have MAO Medicaid, the member must receive an MDCP service within the member’s individual service plan (ISP) year. In the event the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in the current ISP year, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file.
The MCO must include in the documentation the:
- dates during which services are suspended; and
- reason for suspension.
A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.
3327 Reassessment Individual Service Plan
Revision 22-2; Effective September 1, 2022
Managed care organizations (MCOs) must ensure the member's individual service plan (ISP) is submitted annually. If the reassessment ISP is not submitted due to the member's timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.
3328 Process for Reviewing the Individual Service Plan Expiring Report
Revision 22-2; Effective September 1, 2022
Program Support Unit (PSU) staff and managed care organizations (MCOs) will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) monthly to ensure annual reassessments are conducted timely. The ISP Expiring Report lists the MDCP members with ISPs that will expire within the next 90 days.
PSU staff will schedule a monthly conference call with each MCO.
The MCOs must generate the ISP Expiring Report in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal five business days prior to the monthly conference call with PSU staff. The MCO must provide a status update for all MDCP members who have ISPs expiring within the next 45 days. Although the report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update.
3329 Reassessment Notification Requirements
Revision 23-3; Effective July 21, 2023
Program Support Unit (PSU) staff must send Form H2065-D, Notification of Managed Care Program Services, within two business days as notification of reassessment determination.
If the member files a state fair hearing or external medical review within the 10-business day adverse action period (refer to 6100, Ten-Day Adverse Action Notification), within two business days of notification PSU staff must:
- upload Form H2067-MC in MCOHub to the MCO's STAR Kids folder, using the appropriate naming convention, informing the MCO to continue services due to the timely appeal and request for continuation of benefits (if services have already ended, the MCO reinitiates services immediately); and
- extend the end date of the current ISP in the LTC Online Portal four more calendar months.
PSU staff carry out the decision within 10 days of receiving the fair hearings officer's decision.