STAR+PLUS Handbook

STAR+PLUS Handbook Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

 

Section 3000, STAR+PLUS HCBS Program Eligibility and Services

Section 6000, Specific STAR+PLUS HCBS Program Services

Section 7000, STAR+PLUS HCBS Program and Services

Section 8000, Service Delivery Options

Section 9000, Utilization Review Purpose

Section 1000, State of Texas Access Reform Plus (STAR+PLUS) Managed Care

Section 1000, State of Texas Access Reform Plus (STAR+PLUS) Managed Care Anonymous (not verified) Fri, 07/22/2016 - 09:30
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Revision 20-2; Effective October 1, 2020

 

1100 Program Overview

Revision 19-1; Effective June 3, 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), home modifications, respite (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 in order 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 program. For a dictionary of acronyms used in the STAR+PLUS Program, refer to Appendix VII, Acronyms.

 

1110 Legal Basis

Revision 19-1; Effective June 3, 2019

 

Statutory basis for the STAR+PLUS program:

 

1120 Values

Revision 19-1; Effective June 3, 2019

 

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 Service Model

Revision 18-2; Effective September 3, 2018

 

 

 

1131 Service Delivery Model

Revision 19-1; Effective June 3, 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 in 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 are contracted with managed care organizations (MCOs) to 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.)

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 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. If the member chooses to self-direct designated services, the MCO coordinates delivery of non-member-directed designated services. In the CDS model, providers employed by the member or authorized representative (AR) must be qualified personnel to provide all 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. More information is available in Appendix XXVIII, Consumer Directed Services (CDS) Training for Service Coordinators and CDS Training Manual.
  • 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.

 

1140 Program Services

Revision 18-2; Effective September 3, 2018

 

 

 

1141 Services Available Under STAR+PLUS

Revision 19-1; Effective June 3, 2019

 

If the service coordinator identifies a need, or the member requests additional services, the managed care organization (MCO) will assess the member and develop an appropriate individual service plan (ISP). 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-Eligibles, 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.

 

1142 Long-term Services and Supports

Revision 17-5; Effective September 1, 2017

 

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, 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.

 

1143 STAR+PLUS Services

Revision 17-1; Effective March 1, 2017

 

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

  • Section 1143.1, Services Available to STAR+PLUS Members; and
  • Section 1143.2, Services Available to STAR+PLUS Home and Community Based Services (HCBS) Program Members.

 

1143.1 Services Available to STAR+PLUS Members

Revision 19-1; Effective June 3, 2019

 

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 includes all medically-necessary services covered under the traditional, fee-for-service (FFS) Medicaid programs, with the exception of 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 their severe 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.

 

1143.1.1 Services Included Under the MCO Capitation Payment

Revision 19-1; Effective June 3, 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 1143.1.2 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;
  • 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.

 

1143.1.2 Long-term Services and Support Listing

Revision 19-1; Effective June 3, 2019

 

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

  • Community First Choice (CFC) – Available to all Medicaid-eligible members (with the exception of 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 (IMD)). CFC services are provided in a community-based setting. Community-based settings do not include:
    • Hospitals
    • NFs
    • IMDs
    • ICF-IIDs
    • Any setting with the characteristics of an institution
  • CFC services include:
    • Personal assistance services (PAS), which provide assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks;
    • Habilitation services, which provide acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks;
    • Emergency response services (ERS), which are back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports; and
    • Support management, which is training provided to members or the authorized representatives (ARs) on how to manage and dismiss their attendants.
    • Personal Assistance Services (PAS), formerly known as Primary Home Care (PHC) — All members may receive medically and functionally necessary PAS. PAS includes assisting the member with the performance of activities of daily living (ADL) 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 needs and the plan of care (POC). To be eligible for 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. In order to be eligible for PAS through programs other than CFC or 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 (CDS) Option; and
      • Service Responsibility Option (SRO).
  • 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 personal assistance services, therapy extension services, nutrition services, transportation services and other supportive services (PAS). These services are provided at facilities licensed by the state.
  • STAR+PLUS HCBS program 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.
  • NFs — Institutional care to members 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, social services, medications not covered by Medicare Part B or D, medical supplies and equipment, rehabilitative services and personal needs items.

 

1143.1.3 STAR+PLUS Personal Assistance Services (PAS) Practitioner’s Statement of Need (PSON)

Revision 20-2; Effective October 1, 2020

 

State plan personal assistance services (PAS) must be authorized according to 42 Code of Federal Regulations (CFR) §440.167. STAR+PLUS managed care organizations (MCOs) must authorize state plan PAS either in the service plan developed and approved by the MCO for all STAR+PLUS members or by requiring a practitioner’s statement of need (PSON). Note: See Uniform Managed Care Contract Section 8.1.12.4, STAR+PLUS MRSA Contract Section 8.1.13.2 and STAR+PLUS Expansion Contract Section 8.1.13.2. All STAR+PLUS members are considered members with special health care needs.

If the MCO chooses to require a PSON, the PSON may be requested under one or more of the following circumstances:

  • at initial request;
  • if original approval was based on temporary need;
  • if the member experiences a significant change in condition, as defined by managed care contracts; or
  • at reassessment.

A PSON cannot be required for PAS provided under the STAR+PLUS Home and Community Based Services (HCBS) program or Community First Choice (CFC).

Implementing a PSON process should not cause a delay in a prior authorization decision or in delivery of PAS that has been assessed as medically or functionally necessary. The PSON request must be initiated 90 days prior to the expiration of the authorization for PAS, if required upon reassessment. For a significant change in condition, the PSON must be initiated during the 21-day follow-up period for reassessment. The MCO must have a documented process in place for the steps that they will take to follow up with the practitioner to secure the PSON. This process should include the steps that will be taken to notify the member and service provider of the status, including outreach attempts by phone, in writing or in person. The MCO must accept a PSON signature that was gathered by the member or the member’s service provider.

Authorization Extension and Outreach Efforts

Previously authorized services must continue until a signed PSON is obtained. The MCO must have a process in place to extend the authorization to ensure the member has no gap in services while additional outreach efforts are being made by the MCO. The extended authorization period may not exceed 45 additional days.  During the extended authorization period, the MCO must continue outreach to the practitioner and to offer the member the opportunity to change to a new practitioner. The MCO must communicate to the member and the member’s service provider the potential impact to PAS services if a signed PSON is not obtained. The MCO must document in the member’s record all outreach efforts and member education related to the PSON.
 

Required Data Elements

If the STAR+PLUS MCO chooses to require a PSON for STAR+PLUS PAS, the MCO must develop their own version of a PSON. The PSON must include the following separate data elements:

  • Member name;
  • Member identification (ID) number;
  • Member date of birth (DOB);
  • Certification that the member was evaluated by a practitioner in the last 12 months;
  • If the practitioner certifies that they have evaluated the member in the last 12 months, additional certification that the member has a medical diagnosis resulting in one or more functional limitations, as indicated, or that the practitioner is unable to certify the member has a medical diagnosis resulting in one or more functional limitations;
  • Notation of whether the medical diagnosis is resulting in a temporary need, along with the expected end date;
  • All of the items listed in Parts III and IV on Form 3052, Practitioner's Statement of Medical Need;
  • Practitioner printed name;
  • Practitioner address;
  • Practitioner phone number;
  • Practitioner license number;
  • Signature of physician, nurse practitioner, advanced practice registered nurse or physician assistant; and
  • Date form was signed.

The MCO also must provide the practitioner a copy of the completed Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, when requested.

If the MCO has exhausted all efforts to obtain a PSON and intends to deny, limit, reduce, suspend, terminate or make any other adverse determination regarding a member’s services, the MCO must follow the procedures found in the Uniform Managed Care Manual, Chapter 3.21, Medicaid MCO’s Notices of Actions Required Critical Elements.

 

1143.2 Services Available to STAR+PLUS Home and Community Based Services Program Members

Revision 19-1; Effective June 3, 2019

 

Services necessary for the individual 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 — Medical equipment and supplies that include devices, controls or appliances specified in the plan of care (POC) that enable individuals to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live.
  • Adult Foster Care (AFC) — A 24-hour living arrangement for persons who, because of physical or mental limitations, are unable to continue residing in their own homes. Services may include meal preparation, housekeeping, personal care, help with ADL, supervision and the provision of or arrangement of transportation.
  • Assisted Living (AL) Services — A 24-hour living arrangement in licensed personal care facilities in which personal care, home management, escort, social and recreational activities, 24-hour supervision, provision or arrangement of transportation, and supervision of, assistance with and direct administration of medications are provided. Under the STAR+PLUS HCBS program, personal care facilities may contract to provide services in two distinct types of living arrangements:
    • AL apartments; or
    • AL non-apartment settings.
  • Cognitive Rehabilitation Therapy (CRT) — A service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. CRT is provided in accordance with the POC developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
  • Dental Services — Services provided by a dentist to preserve teeth and meet the medical need of the member. Allowable services include:
    • emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection;
    • preventative procedures required to prevent the imminent loss of teeth;
    • the treatment of injuries to teeth or supporting structures;
    • dentures and the cost of preparation and fitting; and
    • routine procedures necessary to maintain good oral health.
  • Emergency Response Services (ERS) — An electronic monitoring system for use by functionally impaired individuals who live alone or are isolated in the community or at high risk of institutionalization. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-days-a-week capability, helps insure that the appropriate persons or service provider respond to an alarm call from the member.
  • Employment Assistance Services (EAS) — Services that assist the member with locating competitive employment or self-employment.
  • Financial Management Services (FMS) — Assistance to members with managing funds associated with services elected for the Consumer Directed Services (CDS) option and is provided by the financial management services agency (FMSA). This service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.
  • Home-Delivered Meals (HDM) — Services that provide nutritionally sound meals delivered to the member’s home.
  • Minor Home Modifications (MHMs) — Services that assess the need for, arrange for and provide modifications or improvements to an individual's residence to enable the individual to reside in the community and to ensure safety, security and accessibility.
  • Nursing Services — Includes, but is not limited to, assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing, developing the health care plan and teaching individuals about proper health maintenance.
  • Occupational Therapy (OT) Services — Interventions and procedures to promote or enhance safety and performance in instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed OT assistant under the direction of a licensed occupational therapist, within the scope of the therapist’s state licensure.
  • Personal Assistance Services (PAS) — Includes assisting the member with the performance of ADL 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 needs and the POC. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing and protective supervision provided solely to ensure the health and welfare of a member with cognitive/memory impairment and/or physical weakness. To be eligible for STAR+PLUS HCBS program 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. STAR+PLUS HCBS program PAS eligibility only requires that the applicant or member needs assistance with at least one personal care task identified on Form H2060. The 24-point scoring eligibility for state plan PAS does not apply to STAR+PLUS HCBS program PAS.
  • Physical Therapy (PT) Services — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Services include the full range of activities provided by a physical therapist or a licensed PT assistant under the direction of a licensed physical therapist, within the scope of the therapist’s state licensure.
  • Respite Care Services — Temporary relief to persons caring for functionally impaired adults in community settings other than Adult Foster Care (AFC) homes or Assisted Living Facilities (ALF). Respite services are provided in-home and out-of-home and are limited to 30 days per individual service plan (ISP) year. Room and board is included in the payment for out-of-home settings.
  • Speech and/or Language Pathology Services — The evaluation and treatment of impairments, disorders or deficiencies related to a member’s speech and language. Services include the full range of activities provided by speech and language pathologists under the scope of their state licensure.
  • Supported Employment Services (SES) — Services that assist the member with sustaining competitive employment or self-employment.
  • Transition Assistance Services (TAS) — Assists members with non-recurring set-up expenses for transitioning from nursing homes to the community. Services may include assistance with security deposits for leases on apartments or homes, essential household furnishings, set-up fees for utilities, moving expenses, pest eradication or one-time cleaning.

 

1200 MCO Service Coordination

Revision 19-1; Effective June 3, 2019

 

Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. 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 identified MCO service coordinator must contact the member at least once telephonically and at least once face-to-face per year. If the member receives STAR+PLUS Home and Community Based Services (HCBS) program, or has a complex medical condition, the identified MCO service coordinator must visit with the member face-to-face at least twice a year. If a member resides in a nursing facility (NF), the MCO service coordinator must meet with the member face-to-face at a minimum of four times per year.

All applicants or recipients 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 member and his or her acute care and LTSS providers to ensure all of a member's medically and functionally necessary services are provided. This includes, but is not limited to, referring and assisting the member in obtaining appointments with specialists, participating in discharge planning for members in hospitals and/or NFs, referring members to community organizations for services, and assistance not covered by Medicaid. Service coordination requirements for members receiving STAR+PLUS HCBS program can be found in Section 3000, STAR+PLUS HCBS Program Eligibility and Services, Section 6000, 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.

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

 

1210 Service Coordinators and Nursing Facilities

Revision 19-1; Effective June 3, 2019

 

Members residing in a nursing facility (NF), (except members receiving hospice care or living outside the managed care organization (MCO) service area), must receive at least quarterly face-to-face visits for assessment purposes. NF staff should invite MCO service coordinators to their resident care planning meetings or other interdisciplinary team meetings, as long as the resident does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or telephonically. The MCO must maintain and make available upon request documentation verifying the occurrence of required face-to-face service coordination visits, which may coincide with or include participation in care planning or other interdisciplinary team meetings.

Service coordination activities for members residing in an NF include, but are not limited to:

  • Visiting members at least quarterly;
    • Assessing the member within 30 days of entry into an NF or enrollment into the health plan;
    • Visiting within 14 days of hearing that a significant change in condition of the member has occurred;
    • Visiting within 14 days of learning that a resident requests a transition to the community;
  • Developing a plan of care (POC) to transition the individual to the community (if appropriate and the resident’s choice);
    • If initial review doesn’t support return to the community, a second assessment will be conducted 90 days after the initial assessment;
  • Transitioning the member to the community in adherence with the Texas Promoting Independence Initiative, including Money Follows the Person (MFP), as appropriate;
    • Notifying the Relocation Contract specialist within three business days after meeting with the member;
    • Notifying the Local Authority for residents meeting Pre-Admission Screening and Resident Review (PASRR) requirements, Local Intellectual and Developmental Disability Authority (LIDDA) or Local Mental Health Authority (LMHA), as appropriate;
    • Working in conjunction with the NF discharge planning team;
    • Coordinating transition with community partners;
    • Coordinating transition if the resident is moving into a service area not served by this MCO, by setting up Single Case Agreements, as needed;
  • Identifying and addressing residents’ physical, mental or long term needs;
  • Assisting residents and families to understand benefits;
  • Ensuring access to and coordination of needed services;
  • Finding providers to address specific needs;
  • Coordinating and notifying of add-on services not included in the daily rate; and
  • Assistance with collection of applied income.
    • NF Business Office manager (BOM) is responsible for collecting applied income.
      • The BOM can notify the MCO service coordinator for assistance in collecting the applied income after two collection attempts are made with no success. The MCO service coordinator's role is to educate the resident and his or her responsible party on the rules regarding payment of applied income to the NF and the potential ramifications of not doing so.
    • If a member participating in the STAR+PLUS Home and Community Based Services (HCBS) program is admitted to an NF, the NF service coordinator must notify the Program Support Unit (PSU) within three business days of the admission using Form H2067-MC, Managed Care Programs Communication.

 

1220 MCO Service Coordinators and Programs Serving Members with Intellectual or Development Disabilities

Revision 19-1; Effective June 3, 2019

 

Individuals who have intellectual or developmental disabilities (IDD) and live in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID) or who receive services through one of the following IDD waivers receive their acute care services only through the STAR+PLUS program and continue to receive their long-term services and supports (LTSS) through the 1915(c) Medicaid waivers:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL).

Individuals who receive services through one of these four programs and receive Medicare Part B (dual eligible) are not included in the STAR+PLUS program.

Members with IDD that meet the above criteria have a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member's or authorized representative's (AR's) personal preference.

These members also have a LIDDA provider that is a person(s) outside of the MCO who develops and implements an individual service plan (ISP) and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member's waiver case manager or service coordinator. The member's waiver case manager or service coordinator should invite MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or telephonically. The MCO service coordinator is responsible for the coordination of the member's acute care services.

 

1230 Service Coordinators and Home and Community Based Services - Adult Mental Health Program

Revision 19-1; Effective June 3, 2019

 

The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves individuals who have severe and persistent mental illness (SPMI) and:

  • a history of extended (three cumulative or consecutive years of the past five years) institutional stays in psychiatric facilities;
  • SPMI and frequent visits to the emergency department; and
  • SPMI and frequent arrests and stays in a correctional facility.

HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program's population. HCBS-AMH is operated on a fee-for-service (FFS) basis through the Texas Health and Human Services Commission (HHSC). Each individual is assigned a recovery manager (RM), who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive their acute care services through their managed care organization (MCO) and their enhanced community-based services from providers contracted with HHSC. Additional information about HCBS-AMH can be found at: https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

Program Point of Contact (PPOC)

  • Each MCO must have a designated PPOC for the AMH program. The PPOC is responsible for the following:
    • Ensuring MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
    • Responding within three business days to concerns from HHSC or RMs to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the AMH program.

MCO Service Coordination Responsibility

  • MCO service coordination must participate in telephonic recovery plan meetings, as scheduled by HHSC or RMs, and provide any requested member-specific information prior to the meeting. MCO service coordinators must:
    • Send requested information to the HHSC or RM three business days prior to the scheduled recovery plan meeting. This information includes, but is not limited to the following:
      • updates regarding member condition;
      • sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
      • upcoming MCO service coordinator face-to-face appointments and/or scheduled dates for telephonic contacts with the member; and
      • relevant member treatment documents as requested by the RM or HHSC.
    • Respond to ad-hoc requests from the RM or HHSC with "urgent" in the subject line within one business day.
    • Respond to non-urgent ad-hoc requests in a timely manner.
    • Coordinate with the Program Support Unit and RM or HHSC when a member transfers from STAR+PLUS Home and Community Based Services (HCBS) program to HCBS-AMH.

HCBS-AMH may provide transitional planning for individuals who reside in an institution and who are also enrolled in a STAR+PLUS MCO. MCO service coordinators must participate in planning meetings with an RM, telephonically or in-person, during the member's stay.  Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution.  MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR+PLUS MCOs must follow all discharge planning requirements as outlined in Uniform Managed Care Contract (UMCC), Section 8.3.2.5.

 

1240 MCO Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 19-1; Effective June 3, 2019

 

The Section 811 Project Rental Assistance (PRA) program provides subsidized rental housing in coordination with supports to individuals with disabilities. Each tenant in the Section 811 PRA program has a “Section 811 service coordinator.” Managed care organization (MCO) service coordinators are the Section 811 service coordinators for STAR+PLUS members discharging from nursing facilities (NFs).

Provision of Services

Once an individual has occupied a Section 811 PRA housing unit, the MCO service coordinator must ensure STAR+PLUS Home and Community Based Services (HCBS) are in place so that the member will be successful in maintaining his or her tenancy. Continued participation in these services is voluntary and not a prerequisite for remaining in Section 811 PRA housing.

The Section 811 PRA program relies on Medicaid services and service coordination to provide the supports an individual needs to remain safely in the community. The MCO service coordinator is responsible for informing individuals in NFs about the availability of this program and if they are interested, to assist them in submitting an application and required documentation. The MCO may delegate this responsibility to the relocation specialist. If eligible, the MCO service coordinator must assist eligible individuals in accessing funding available to assist with relocations.

Communication between MCO and Texas Health and Human Services Commission (HHSC)

The MCO service coordinator must coordinate with the HHSC Section 811 Point of Contact (HHSC POC) on an ongoing basis regarding members participating in the Section 811 PRA program. The HHSC POC is listed on the Texas Department of Housing and Community Affairs (TDHCA) Section 811 PRA webpage: https://www.tdhca.state.tx.us/section-811-pra/contact.htm.

MCO Responsibilities – Helping Potential Applicants

Information on such laws and requirements will be conveyed at training provided by TDHCA and in the Texas Section 811 PRA Program Service Coordinator Manual. Specific responsibilities of the Section 811 service coordinator are listed below:

  • Assist in recruiting and pre-screening potential participants;
  • The MCO service coordinator or relocation specialist will assist individuals in accessing Section 811 PRA housing;
    • Inform NF residents who have indicated an interest in moving to the community about the availability of the Section 811 PRA program. Inform individuals who transitioned from an NF to the community within the past 12 months about the availability of the Section 811 PRA program;
    • Assist interested individuals in reviewing available properties and their leasing criteria on the TDHCA website (http://tdhca.state.tx.us/section-811-pra/participating-properties.htm);
    • Using information provided by TDHCA, inform interested individuals about the potential wait time for an available unit;
    • Assist interested individuals in completing an application for tenancy and compiling necessary documentation;
    • Ensure that all methods of outreach and referral are consistent with fair housing and civil rights, laws and regulations, and affirmative marketing requirements; and
  • Assist residents in maintaining their housing.

MCO Point of Contact Requirements – for Potential Applicants

For members who have applied to the Section 811 PRA program, the MCO must update information that was collected at the time of application to the program, if anything changes. This will ensure the member can be contacted and the information on file with TDHCA is accurate. The MCO must ensure the HHSC Section 811 POC and the TDHCA POC have the means to identify and contact the member within one business day of receiving a notice that a Section 811 PRA program unit is available.

MCO Responsibilities – for Existing Tenants

Once an individual has been accepted for tenancy in a Section 811 PRA program unit, the MCO service coordinator will provide the following support to assist individuals in maintaining their housing:

  • Subject to an individual's agreement to share this information, respond to any inquiry from the HHSC Section 811 POC relating to a member's participation in the Section 811 PRA program, including the services the member is receiving and who the service providers are;
  • Fulfill the obligations of the Section 811 service coordinator in the Conflict Management process set forth in the Texas Section 811 PRA Program Service Coordinator Manual, including:
    • Working with the Section 811 POC and the Section 811 PRA program property owner or the property owner's designated agent (such as the property management company) in the event there is an incident, including a lease violation which could jeopardize the individual's ability to maintain his or her tenancy in a Section 811 PRA program; and
    • Work with the Section 811 POC and the Section 811 PRA program owner or the owner's designated agent to support the member in such a way that they do not lose their housing as a result of a lack of services or a lack of coordination of services. As a tenant in a Section 811 PRA program unit, a member may refuse services and this does not place his or her housing at risk.

The MCO must ensure the HHSC POC and the TDHCA POC have the means to identify and contact an individual's Section 811 service coordinator within one business day of receiving notice of a concern from the Section PRA program owner, owner's designee, or TDHCA POC.

MCO Point of Contact Requirements – for Existing Tenants

MCO service coordinators serving members who are participating in the Section 811 PRA program must ensure that the HHSC POC has the MCO service coordinator’s contact information. If the MCO service coordinator information changes or is no longer fulfilling the roles and responsibilities associated with the Section 811 PRA program for a member, the MCO service coordinator must notify the HHSC POC.

Additional references for Section 811 Program Requirements for MCOs

MCO service coordinators serving members exiting an NF or other institution and who are participating in the Section 811 PRA program must comply with the roles and responsibilities assigned to them in the Inter-Agency Partnership Agreement (HHSC Contract No. 529-12-0134-00001), as amended and as applicable, and MCO service coordinators agree to fulfill the obligations assigned to Section 811 service coordinators in accordance with the Texas Section 811 PRA Program Service Coordinator Manual.

MCO service coordinators serving members who are participating in the Section 811 PRA program may download and read the Texas Section 811 PRA Program Service Coordinator Manual, available on TDHCA's webpage.

If requested by HHSC, the MCO service coordinator or designee must attend training on the Section 811 PRA program. Trainings can include, but are not limited to, in-person training, webinars, conference calls or responding to requests via email.

 

1250 Service Coordinators and the Medicaid for Breast and Cervical Cancer Program

Revision 19-1; Effective June 3, 2019

 

Individuals eligible for Medicaid through the Medicaid for Breast and Cervical Cancer (MBCC) program are a mandatory population in the STAR+PLUS program. The MBCC program provides Medicaid services including, but not limited to, the treatment of cancer and precancerous conditions for individuals with qualifying diagnoses between age 18 and their 65th birth month. An MBCC program member 18 to 20 years of age will be enrolled in STAR+PLUS. Eligibility for the MBCC program allows an individual under the age of 21 to participate in the STAR+PLUS program. Individuals in the MBCC program receive their Medicaid services through their STAR+PLUS managed care organization (MCO). The individual will be assigned a named service coordinator and receive at a minimum one telephonic contact and one face-to-face visit annually, unless otherwise requested by the MBCC member.

The MCO service coordinator assists the MBCC member with coordinating care. Coordination can include, but is not limited to, assistance with renewing Medicaid eligibility by reminding and assisting with paperwork. Continued participation in MBCC requires a completed MBCC renewal application and physician attestation the individual requires continued, active treatment for breast or cervical cancer or pre-cancer. The physician attestation and eligibility paperwork must be submitted every six months.

An MBCC individual under 21 can also be on the Medically Dependent Children Program (MDCP) interest list. If the individual reaches the top of the MDCP interest list, the individual can transfer from STAR+PLUS into MDCP since MDCP provides additional services not available in STAR+PLUS or the STAR+PLUS HCBS programs. Upon release from the MDCP interest list, the individual will be processed as a STAR member transitioning to MDCP.

When the individual reaches age 21, the MDCP member will transfer to STAR+PLUS HCBS program as a medical assistance only (MAO) upgrade using the high needs transition process.

MBCC members age 21 or older requesting STAR+PLUS HCBS program services can be upgraded to the STAR+PLUS HCBS program without going on the interest list. However, PSU staff must send an enrollment packet that includes Form H1200, Application for Assistance – Your Texas Benefits, as Medicaid for the Elderly and People with Disabilities (MEPD) is required to assess the Medicaid application using ME-Waiver eligibility rules.

After the enrollment packet is received, PSU staff will send Form H1200, along with Form H1746-A, MEPD Referral Cover Sheet, to MEPD. If the individual is eligible as an MAO applicant, MEPD will change the individual’s Medicaid from MBCC to ME-Waivers in the Texas Integrated Eligibility Redesign System (TIERS).

Section 2000, Legal Requirements

Section 2000, Legal Requirements Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

Revision 19-1; Effective June 3, 2019

 

2100 Disclosure of Information

Revision 18-2; Effective September 3, 2018

 

 

 

2110 Confidential Nature of the Case Record

Revision 18-2; Effective September 3, 2018

 

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 a member.

A 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.

 

2111 Verifying the Identity of an Applicant, Member, Authorized Representative or Third Party Individual

Revision 19-1; Effective June 3, 2019

 

Keep all information that the Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) have about a member or authorized representative (AR) on the member's case confidential. Confidential information includes, member’s name, date of birth (DOB), address, Social Security number (SSN), Medicaid identification (ID) number or any other individually identifiable health information.

Before discussing or releasing information about a member or AR on the member's case, take steps to be reasonably sure the individual receiving the confidential information is either the member or an individual the member has authorized to receive confidential information (for example, an attorney or AR).

 

2111.1 Telephone Communication

Revision 19-1; Effective June 3, 2019

 

Establish the identity of an individual who identifies herself or himself as an applicant or member by verifying the individual’s knowledge of any of the following:

  • applicant's or member’s Social Security number (SSN) and date of birth (DOB);
  • member’s DOB and Medicaid ID number;
  • member’s SSN and answer to a security question;
  • member’s DOB and answer to a security question; or
  • answer two security questions.

Establish the identity of an AR by using the individual's knowledge of any of the above and any of the following:

  • AR's SSN and DOB;
  • AR’s SSN and answer to a security question;
  • AR’s DOB and answer to a security question; or
  • answer two security questions.

Establish the identity of attorneys or AR by asking for the individual to provide Form 1826-D, Case Information Release, or a document that contains all of the information listed in Section 2114, Information That May Be Disclosed, completed and signed by the member. The managed care organization (MCO) must maintain this documentation in the member's case file.

 

2111.2 In-Person Contact Communication

Revision 19-1; Effective June 3, 2019

 

Establish the identity of the individual who presents herself or himself as an applicant, member or member's authorized representative (AR) at a Texas Health and Human Services Commission (HHSC) or managed care organization (MCO) office by examining:

At least one form of government-issued photo identification (ID):

  • valid U.S. passport;
  • Texas Department of Public Safety (DPS) driver license or identification (ID) card;
  • DPS Texas Election Identification Certificate;
  • DPS handgun license;
  • U.S. military ID card containing the photograph; or
  • state agency employee badge; and

At least one form of other identification:

  • birth certificate or birth record;
  • Social Security Number (SSN) card;
  • Medicaid ID card;
  • hospital record;
  • work or school ID card;
  • voter registration card;
  • wage stub;
  • credit card (including gas cards);
  • department store credit card;
  • annual plastic membership ID card; or
  • utility bill.

Establish the identity of other HHSC or MCO staff, federal agency staff, researchers 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 the HHSC Office of Chief Counsel.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers or other HHSC or MCO staff come to the office without prior notification or adequate identification and request permission to access records.

Refer to Section 2111.4, Verification and Documentation of Disclosure, if the individual is requesting personally identifiable information (PII) or PHI.

 

2111.3 Electronic Mail Communication

Revision 19-1; Effective June 3, 2019

 

If managed care organization (MCO) staff receive electronic mail, also known as email, from an applicant, member, authorized representative (AR) or a third party that contains protected health information (PHI), MCO staff must respond by:

  • copying the original inquiry to a new email, removing PHI from the original request;
  • indicate in the response that PHI has been removed from the original email; and
  • respond without using PHI.

If the answer to the inquiry requires the inclusion of PHI, MCO staff must respond by:

  • copying the original inquiry to a new email, removing PHI from the original request;
  • notify the sender this is not a secure method of PHI transmission; and
  • request the sender submit their request in writing via mail or facsimile.

MCO staff must not send PHI by email to non-government entity individuals, including applicants, members, ARs or third-party individuals. Refer to Section 2111.4, 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.

MCO staff may share PHI by email with Medicaid for the Elderly and People with Disabilities (MEPD), Texas Medicaid & Healthcare Partnership (TMHP), the 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."

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

 

2111.4 Verification and Documentation of Disclosure

Revision 19-1; Effective June 3, 2019

 

It is only acceptable to disclose personally identifiable information (PII) or protected health information (PHI) to the applicant, member, authorized representative (AR) or a third-party to whom the applicant, member, or AR have provided written consent for the release of PII or PHI information. If disclosing PII or PHI, document transactions and maintain documentation in the member’s case file pertaining to how the identity of the person was verified when contact is outside the interview and the method of how the information was released to the individual.

Verify the identity of the person who requests disclosure of PII or PHI by examining:

At least one form of government-issued photo identification (ID):

  • valid United States (U.S.) passport;
  • Texas Department of Public Safety (DPS) driver license ID card;
  • 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; or
  • state agency employee badge; and

At least one form of other ID:

  • birth certificate or birth record;
  • Social Security number (SSN) card;
  • Medicaid ID card;
  • hospital record;
  • work or school identification card;
  • voter registration card;
  • wage stub;
  • credit card (including gas cards);
  • department store credit card;
  • annual plastic membership ID card; or
  • utility bill.

Refer to Section 2111.1, Telephone Communication, Section 2111.2, In-Person Communication, and Section 2140, Communication with the Applicant or Member, for acceptable communication channels for external partners.

 

2112 Custody of Records

Revision 19-1; Effective June 3, 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 and managed care organization (MCO) 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.

 

2113 Disposal of Records

Revision 18-2; Effective September 3, 2018

 

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. Managed care organizations (MCOs) must follow procedures contained in the Uniform Managed Care Contract.

 

2114 Information That May Be Disclosed

Revision 19-1; Effective June 3, 2019

 

Reasonable efforts must be made to limit the use, request or disclosure of protected health information (PHI) to the minimum necessary to determine eligibility and operate the program. The disclosure of the applicant’s or member’s PHI from Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records must be limited to the minimum necessary to accomplish the requested disclosure. For example, if an applicant or member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the applicant or member.

PHI may only be disclosed to a person who has written permission from the applicant, member or authorized representative (AR) to obtain the information. The applicant, member or AR authorizes the release of information by completing and signing:

  • Form 1826-D, Case Information Release; or
  • a document containing all of the following information:
    • the applicant's or member's:
      • full name (including middle initial) and Medicaid identification number; or
      • full name (including middle initial) and either date of birth or Social Security number (SSN);
    • a description of the information to be released. Note: If a general release is authorized, provide the information that can be disclosed to the applicant, member or AR. Withhold PHI from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
    • a statement specifically authorizing HHSC or the MCO to release the information;
    • the name of the person or agency to whom the information will be released;
    • the purpose of the release;
    • an expiration event that is related to the member, the purpose of the release or an expiration date of the release;
    • a statement about whether refusal to sign the release affects eligibility for delivery of services;
    • a statement describing the applicant's or member's right to revoke the authorization to release information;
    • the date the document is signed; and
    • the signature of the applicant, member or AR.

Note: If the case information to be released includes PHI, the case release of information document must also tell the applicant, member or AR that information released under the document may no longer be private, and may be released further by the person receiving the information.

Occasionally requests for information from the case records of deceased members are received. In these instances, protect the confidentiality of the former members and the members' survivors.

The Office of Chief General Counsel at HHSC handles questions about the release of information under the Open Records Act. All questions and problems encountered by individuals concerning release of information should be referred to these offices. MCO staff should contact HHSC’s Managed Care Compliance & Operations (MCCO).

 

2115 Confidential Nature of Medical Information — HIPAA

Revision 19-1; Effective June 3, 2019

 

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 individual and that relates to the:

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

PHI includes, but is not limited to, an individual's name, date of birth (DOB), address, Social Security number (SSN), and Medicaid ID number.

 

2116 Privacy Notice

Revision 19-1; Effective June 3, 2019

 

Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) staff must send each member the Health and Human Services Agencies' Notice of Privacy Practices at https://hhs.texas.gov/health-and-human-services-agencies-notice-privacy-practices, upon certification. This notice tells the member or authorized representative (AR) about:

  • the member's privacy rights;
  • the duties of HHSC and the MCO to protect health information; and
  • how HHSC and the MCO may use or disclose health information without the member's authorization. Examples of use or disclosure include health care operations (e.g., Medicaid), public health purposes, reporting victims of abuse, law enforcement purposes, sharing with HHSC or MCO contractors and coordinating government programs that provide benefits.

 

2117 Authorized Representatives

Revision 19-1; Effective June 3, 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’s 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) and the managed care organization (MCO) are not required to disclose the information to the AR if the member is subjected to domestic violence, abuse or neglect by the AR. Consult the Office of Chief Counsel, as described in Section 2114, Information That 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.

 

2117.1 Adults and Emancipated Minors

Revision 19-1; Effective June 3, 2019

 

If the member is an adult or emancipated minor, including married minors, the member's authorized representative (AR) is a person who has the authority to make health care decisions about the member and includes a:

  • person the 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 member; or
  • person designated by law to make health care decisions when the member is in a hospital or nursing home 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 2114, Information That May Be Disclosed, for approval.

 

2117.2 Unemancipated Minors

Revision 19-1; Effective June 3, 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 United States (U.S.) military;
    • minor is age 16 or older, lives separately from the parents and manages her or his 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;
    • 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.

 

2117.3 Deceased Applicant or Member

Revision 19-1; Effective June 3, 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 Council, as described in Section 2114, Information That May Be Disclosed, about whether a particular person is the AR of an applicant or member.

 

2120 Applicant or Member Correction of Information

Revision 19-1; Effective June 3, 2019

 

An applicant, member or authorized representative (AR) has a right to correct any information that 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 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.

If HHSC or the MCO agrees to change protected health information (PHI), the corrected information is added to the case record, but 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 MCO needs to extend the 60-day period by an additional 30 days to complete the correction process or obtain additional information.

If HHSC or the MCO makes a correction to PHI, HHSC or the MCO must ask the member for permission before sharing with third parties. 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’s to the disadvantage of the member. HHSC staff must contact the HHSC Office of Chief Counsel for a record of disclosures. MCOs must follow HHSC procedures as stated in the Uniform Managed Care Contract, Section 11.03, Member Records.

Note: Do not follow above procedures when the accuracy of information provided by an applicant, 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.

 

2130 Communication with the Managed Care Organization

Revision 19-1; Effective June 3, 2019

 

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is imperative for a member's protected health information (PHI) to be shared only with the selected managed care organization (MCO). This makes it crucial that when documents containing member information are uploaded in the incorrect MCO folder in TxMedCentral, they be corrected immediately upon realization an error was made.

Send notification of all uploading errors to txmedcentraladmin@tmhp.com. Include the document identifying information, the name of the folder in which it was erroneously uploaded and the name of the folder into which it should have been uploaded. Include the time the correction was made.

Example: Posted 9F_2067_123456789_ABCD_2S.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.

All emails containing member information must be sent using encryption software. No PHI may appear in the subject line.

See also:

 

2140 Communication with the Applicant or Member

Revision 19-1; Effective June 3, 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.

 

2200 Member Rights and Responsibilities

Revision 19-1; Effective June 3, 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/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the member at application. This document is shared in the language preference expressed by the applicant/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.

 

2210 Notifications

Revision 19-1; Effective June 3, 2019

 

 

 

2211 Program Support Unit Notification Requirements

Revision 19-1; Effective June 3, 2019

 

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 program eligibility and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member or AR of the actions taken regarding STAR+PLUS Home and Community Based Services (HCBS) program. Form H2065-D must be completed in plain language that can be understood by the applicant, member or AR. The language preference of the applicant, member or AR must be considered.

The applicant, member or AR must be notified on Form H2065-D within two business days of the date a case is certified. Form H2065-D also includes information on the individual's room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant who is denied program eligibility or a member whose program eligibility is denied or terminated. The PSU staff must notify the applicant, member or AR on Form H2065-D of the denial of application within two business days of the decision. Refer to Section 3630, Denial or Termination Procedures.

Depending on when the notification is generated, it will either be uploaded to the managed care organization’s (MCO’s) STAR+PLUS folder, following the instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance, on the case action date.

 

2212 MCO Notification Requirements

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) is responsible for notifying the member or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member or AR has a right to appeal. Appeal rights of STAR+PLUS members are in the Uniform Managed Care Manual (UMCM), which can be found at: https://hhs.texas.gov/services/health/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

 

2220 Notifications with MEPD Involvement

Revision 19-1; Effective June 3, 2019

 

Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialist. The Program Support Unit (PSU) staff must coordinate changes, approvals and denials of Home and Community Based Services (HCBS) program services with the MEPD specialist.

Although the MEPD specialist is required to notify the applicant, member or authorized representative (AR) of all Medicaid eligibility decisions, the PSU is required to send the STAR+PLUS HCBS program applicant, member or AR the notification of denial of STAR+PLUS HCBS program services on Form H2065-D, Notification of Managed Care Program Services.

Section 3000, STAR+PLUS HCBS Program Eligibility and Services

Section 3000, STAR+PLUS HCBS Program Eligibility and Services Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

Revision 21-2; Effective August 1, 2021

 

3100 Ancillary Member Resources

Revision 18-2; Effective September 3, 2018

 

 

 

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 Section 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 Section 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 Section 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 18-2; Effective September 3, 2018

 

Prescription drugs are not part of the managed care organization's (MCO's) array of services. STAR+PLUS Medicaid-only members continue to have prescriptions filled by any pharmacist participating in the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP). They will receive unlimited medically necessary prescriptions instead of the traditional three prescriptions per month limit. Drug coverage through VDP is limited to the state's formulary and may not cover all of the prescribed medications required for the individual.

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-eligible) receive the majority of their drugs through Medicare Part D.

The MCO must inform individuals requesting the STAR+PLUS program of prescription coverage available through the STAR+PLUS program and the Medicare Part D program. The following information regarding the impact of the Medicare Part D program on members must be explained to the applicant:

  • 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 VDP.
  • Drug coverage through Medicare is limited to each drug plan's formulary and may not cover all of the prescribed medications required for the member. Prescriptions not covered by Medicare Part D may be paid by the Medicaid Vendor Drug Program; however, the Medicaid Vendor Drug formulary does not cover certain prescription drugs and over-the-counter medications.
  • 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.
  • Members not participating, or those choosing private insurance over Medicare Part D, are also responsible for purchasing medications and copayments for medications not covered by Medicare Part D or the Medicaid VDP.
  • Members eligible for both Medicare and Medicaid can receive assistance with prescription costs through the Low Income Subsidy program. These members pay little or no premiums and no deductibles. Drug copayment amounts could range from $1 to $5.

Federal law prohibits the use of STAR+PLUS program funds for Medicare Part D prescriptions, copayments and costs. STAR+PLUS program funds may not be authorized for prescriptions, copayments and costs if the member is eligible for Medicare Part D and chooses private insurance rather than participation in Medicare Part D. Non-covered medications cannot be billed through the STAR+PLUS program as medical supplies or adaptive aids.

Copayments for prescriptions covered by the Veterans Benefits Administration may be authorized as an adaptive aid through the STAR+PLUS program.

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 (AL) or adult foster care (AFC) services.

For a member whose current Medicaid identification card does not include the statement "can receive more than three prescriptions," pharmacists may verify the STAR+PLUS program eligibility for more than three prescriptions by calling Pharmacy Billing at 1-800-435-4165.

A list of the STAR+PLUS program enrollments is sent to the Medicaid VDP daily. VDP staff register the member on the system within two days after the member's enrollment record is registered for STAR+PLUS Program services.

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

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 as incurred medical expenses. Refer to Section 3123, Incurred Medical Expenses.

 

3122 Over-the-Counter Drugs

Revision 18-2; Effective September 3, 2018

 

The STAR+PLUS Home and Community Based Services (HCBS) program does not pay for over-the-counter drugs, with or without a prescription or statement from a physician or health professional. Over-the-counter drugs are generally considered medications that may be sold to a customer without a prescription and do not require the direct supervision of a physician or health professional. Common over-the-counter medications include pain relievers, decongestants, antihistamines, cough medicines, vitamins, minerals and herbal supplements. This list is not all inclusive.

Medications, including over-the-counter drugs not covered through the Texas Health and Human Services Commission (HHSC) Vendor Drug Program (VDP), Medicare Part D or other third-party resources (TPR), cannot be paid for by the STAR+PLUS HCBS program. Refer to Section 3121, Prescription Drugs, for additional information.

 

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.

 

3200 Eligibility

Revision 18-2; Effective September 3, 2018

 

 

 

3210 Service Areas

Revision 18-2; Effective September 3, 2018

 

STAR+PLUS services are currently available statewide, broken down service delivery areas:

Bexar Service Area: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties
Dallas Service Area: Collin, Dallas, Ellis, Hunt, Kaufman, Navarro and Rockwell counties
Harris Service Area: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller and Wharton counties
El Paso Service Area: El Paso and Hudspeth counties
Hidalgo Service Area: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Starr, Webb, Willacy and Zapata counties
Jefferson Service Area: Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler and Walker counties
Lubbock Service Area: Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher and Terry counties
Medicaid Rural Service Area (MRSA) Central Texas Service Area: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, DeWitt, Erath, Falls, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, Somervell and Washington counties
Medicaid RSA Northeast Texas Service Area: Anderson, Angelina, Bowie, Camp, Cass, Cherokee, Cooke, Delta, Fannin, Franklin, Grayson, Gregg, Harrison, Henderson, Hopkins, Houston, Lamar, Marion, Montague, Morris, Nacogdoches, Panola, Rains, Red River, Rusk, Sabine, San Augustine, Shelby, Smith, Titus, Trinity, Upshur, Van Zandt and Wood counties
Medicaid RSA West Texas Service Area: Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallam, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Yoakum, Young and Zavala counties
Nueces Service Area: Aransas, Bee, Brooks, Calhoun, Goliad, Jim Wells, Karnes, Kennedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria counties
Tarrant Service Area: Denton, Hood, Johnson, Parker, Tarrant, and Wise counties
Travis Service Area: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties

 

3220 Eligible Groups

Revision 18-2; Effective September 3, 2018

 

 

 

3221 Mandatory Groups

Revision 18-2; Effective September 3, 2018

 

The following groups of individuals must receive services through STAR+PLUS. The program designations are used in the following list.

  • Supplemental Security Income (SSI) recipients, Texas Integrated Eligibility Redesign System (TIERS) TA 01, TA 02 and TA 22 — Individuals age 21 or over who qualify for this needs-tested program administered by the Social Security Administration (SSA) (full Medicaid recipients).
  • Pickle Amendment Group, TIERS TP 03 — Individuals age 21 or over who would continue to be eligible for SSI benefits if cost of living increases (COLAs) were deducted from their countable income.
  • Disabled Widow(s) or Widower(s), TIERS TP 21 — Widow(s) or widower(s), age 60-65 and with a disability, who:
    • were denied SSI benefits because of entitlement to early age widow's or widower's benefits;
    • are ineligible for Medicare; and
    • would continue to be eligible for SSI benefits in the absence of those early aged widow's/widower's benefits and any increases in those benefits.
  • Another group of TIERS TP 22 recipients include early widow(s) or widower(s), aged 50-60 and with a disability, who:
    • are ineligible for Medicare and were denied SSI due to an increase in widow's or widower's benefits as a result of the relaxing of disability criteria; and
    • would continue to qualify for SSI with the exclusion of the Retirement, Survivors and Disability Insurance (RSDI) benefit and all COLA increases.
  • Disabled Adult Children, TIERS TP 18 — Adults over age 21 with a disability that began before age 22 who would continue to be eligible for SSI benefits if qualified RSDI disabled adult children's benefits are excluded from countable income.
  • Medicaid Buy-In, TIERS TP 87 (designated in TIERS as "ME — Medicaid Buy In") — Disabled working adults over age 21 who receive full Medicaid benefits as a result of buying into the Medicaid program.
  • Medicaid for Breast and Cervical Cancer recipients, TIERS TA 67 —  Individuals aged 18 to the 65th birth month who meet eligibility requirements defined in Texas Administrative Code, Title 1 Part 15, Chapter 366, Subchapter D.
  • STAR+PLUS Home and Community Based Services (HCBS) program recipients who are medical assistance only (MAO), TIERS TA 10 (ME-Waiver) — Individuals who are eligible for STAR+PLUS because they participate in the STAR+PLUS HCBS program. 
  • Most nursing facility (NF) residents, TIERS TP 38 or TA06 (SSI) or TP 17 (MAO) — Most individuals residing in an NF.

The TIERS TA 10 identifier also designates individuals in Home and Community-based Services (HCS), Medically Dependent Children Program (MDCP) and Community Living Assistance and Support Services (CLASS). Because HCS, CLASS and MDCP individuals are excluded from STAR+PLUS, if a TIERS TA 10 recipient is identified as receiving one of these excluded services, contact the Program Support Unit (PSU) and provide the details for disenrollment from STAR+PLUS.

 

3222 Excluded Groups

Revision 17-1; Effective March 1, 2017

 

For excluded groups, refer to Texas Administrative Code (TAC) §353.603, Member Participation.

 

3223 Hospice Services in STAR+PLUS

Revision 18-2; Effective September 3, 2018

 

Hospice services may be delivered in a variety of settings, including nursing facilities (NFs). STAR+PLUS members must not be denied services or disenrolled due to receipt of hospice services. Hospice provides services related to terminal illness that are not available under the STAR+PLUS program. For example, hospice providers are able to administer pain control medications that are not available to STAR+PLUS providers.

NF hospice services can be identified in the Service Authorization System Online (SASO) as Service Group (SG) 8, Service Code (SC) 31. The NF counter is activated by non-hospice NF authorizations, which appear in SAS as SG1/SC1 or SG1/SC3.

 

3230 Financial Eligibility

Revision 18-2; Effective September 3, 2018

 

STAR+PLUS Home and Community Based Services (HCBS) program applicants who are not already Medicaid eligible are required to complete Form H1200, Application for Assistance – Your Texas Benefits, in order to be evaluated for financial eligibility. The completed application form must be sent to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist by close of business of the second business day from receipt. The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

Application for Assistance – Your Texas Benefits, in order to be evaluated for financial eligibility. The completed application form must be sent to the MEPD specialist by close of business of the second business day from receipt. The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.

Applicants have 30 days from the mail date of the application to complete, sign and return Form H1200. After 30 days, the application must be denied for failure to return the information needed to determine financial eligibility. Before denying the application, Program Support Unit (PSU) staff must check first to make sure the application form was not mailed directly to the MEPD specialist.

If denial is necessary, document "Your application is being denied because you failed to return the application form mailed to you on [date]" in the comments section of Form H2065-D, Notification of Managed Care Program Services.

See Section 3112, Medicaid Eligibility, for additional information regarding financial eligibility for the STAR+PLUS HCBS program.

 

3231 Income Diversion Trust

Revision 21-2; Effective August 1, 2021

 

An applicant who has a qualified income trust (QIT) may be determined eligible for the STAR+PLUS Home and Community Based Services (HCBS) program even though her or his income is greater than the special institutional income limit, if the applicant also meets all other eligibility criteria. Income converted to the trust does not count for purposes of determining financial eligibility by Medicaid for the Elderly and People with Disabilities (MEPD) specialists; however, the total income (including income diverted to the trust) is considered for the calculation of copayment for STAR+PLUS HCBS program services. An applicant may be eligible for services if all other eligibility criteria are met, even if the amount he or she has available for copayment equals or exceeds the total cost of her or his individual service plan (ISP).

Financial eligibility for an applicant with a QIT is determined by the MEPD specialist. He or she is informed that any funds deposited into the trust must be used as copayment for the cost of services delivered. The MEPD specialist calculates the amount of income available from the trust for copayment and provides the amount to the Program Support Unit (PSU) staff. PSU staff notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication.

For an applicant who is financially eligible based on a QIT, the eligibility based on the ISP cost limit is determined before considering the use of funds from the trust for the purchase of services. Funds from the trust determined to be available for copayment are used to purchase STAR+PLUS HCBS program services for the individual but are not used to reduce the cost of the ISP until after eligibility is determined to avoid the possibility of "purchase" of STAR+PLUS HCBS program eligibility. A member with a QIT copayment that covers all STAR+PLUS HCBS program costs receives the benefit of contracted rates as opposed to private pay rates.

First, a plan of care (POC) is developed by the MCO without consideration of the trust. Then, if the individual is eligible for the STAR+PLUS HCBS program based on the cost limit, the excess funds from the trust (the monthly income in excess of the institutional income limit and allowable deductions for a spouse's needs and medical expenses) are allocated to pay for services identified on Form H1700-1, Individual Service Plan, as the STAR+PLUS HCBS program. The ISP total, and therefore the amount of the authorizations to providers, is reduced by the amount of excess funds. The member must pay the provider directly for the amount of services equivalent to the amount of excess funds. Use of the trust fund is documented on Form H1700-2, Individual Service Plan – Addendum. Continuing Medicaid eligibility through the STAR+PLUS HCBS program is contingent upon payment of the QIT copayment to the provider(s).

Refer to Section 3236, Copayment and Room and Board, and Section 3232, Payments from the Qualified Income Trust, for specific PSU and MCO procedures related to QIT copayments.

 

3232 Payments from the Qualified Income Trust

Revision 21-2; Effective August 1, 2021

 

Applicants or members with a qualified income trust (QIT) are responsible for a copayment in adult foster care (AFC), assisted living (AL) or the at-home setting. The managed care organization (MCO) must clearly explain to the applicant or member the funds from the QIT determined to be available for copayment must be used to purchase the STAR+PLUS Home and Community Based Services (HCBS) program. Payments are made directly to the AFC, AL or other provider.

For applicants or members residing in AFC or AL settings, the copayment amount is usually applied to the cost of AFC or AL first. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other STAR+PLUS HCBS program services, such as nursing, personal assistance services (PAS) or medical supplies. For applicants or members at home, the copayment is first used to purchase PAS, nursing or medical supplies. The MCO calculates the type and amount of payment the applicant or member will make directly to the service provider using the following steps:

  • The MCO develops the individual service plan (ISP) showing the total requested services and total cost of the ISP without consideration of the amount of services the QIT copayment will purchase.
  • Once the ISP has been developed, the MCO uses the QIT copayment amount provided by Medicaid for the Elderly and People with Disabilities MEPD specialist to determine the units of service to be purchased from the trust. The units of service are determined by dividing the monthly copayment amount by the unit rate for the service and rounding the result to the next lower half unit. The MCO documents the amount of services the member must pay directly to the provider(s) and obtains the applicant's or member's agreement. Refer to Section 3234, Qualified Income Trust Copayment Agreement, for specific details about documenting the agreement.
  • The MCO develops a second Form H1700-1, Individual Service Plan, to reflect the amount of services reduced by the QIT copayment amount. The second Form H1700-1 is annotated in the top margin as "Adjusted ISP for QIT Copayment." For the service category where the QIT payment will be applied, the monthly units to be purchased through the copayment are multiplied by 12 to determine an annual amount of services to be purchased. This amount is subtracted from the total authorized amount to determine the new service units to be authorized and the new ISP total. Form H1700-2, Individual Service Plan – Addendum, is used to document the specific services provided through the QIT.
  • The amounts on the adjusted ISP are entered into the Service Authorization System Online (SASO). The total available QIT copayment amount is not entered on Form H1700-1 and is not reflected in SASO copayment screens for QIT members living at home. If the member lives in an AFC or AL setting, the calculated QIT copayment amount will be reflected in the Copayment screens in SASO. Refer to the information in Section 3233, Available QIT Copayment Amount Exceeds the Daily Rate for AFC or AL, if the available QIT copayment amount is sufficient to fully pay for AFC or AL. The copayment amount for services other than AFC or AL is documented on Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and Form H2065-D, Notification of Managed Care Program Services.
  • The adjusted ISP and Form 1578 are sent to the service provider(s). The provider will review the adjusted ISP and attachments to determine the acceptance of a referral.
  • Form H2065-D is used to notify the member and provider(s) of the amount of copayment to be made directly to the provider(s). QIT copayment amounts to the MCO contracted provider are shown on Form H2065-D in the comments section.

 

3233 Available QIT Copayment Amount Exceeds the Daily Rate for Adult Foster Care or Assisted Living

Revision 18-2; Effective September 3, 2018

 

If the available qualified income trust (QIT) copayment amount exceeds the daily rate for adult foster care (AFC) or assisted living (AL), the monthly AFC or AL copayment amount must be calculated using the exact number of days in each month (28, 30 or 31 days).

Example: The available QIT copayment amount is $1,400 monthly. The member is authorized as AL Apartment. The daily rate is $42.18. For April, the monthly copayment amount is $1,265.40 ($42.18 multiplied by 30 days in April). For May, the monthly copayment amount is $1,307.58 ($42.18 multiplied by 31 days in May).

The managed care organization (MCO) may complete Form 1578, Qualified Income Trust (QIT) Copayment Agreement, each month or complete the copayment amount for several months in the future. If the copayment amount changes for any of the months the member has been notified of in advance, Form 1578 must be sent to reflect the new copayment amounts for each month. The MCO must maintain a copy of each Form 1578 in the member's folder.

If any QIT copayment amount remains after the monthly copayment amount is calculated for the AFC or AL setting, the remaining copayment amount is applied to services delivered by the in-home provider. In these cases, the AFC or AL provider, in-home provider, member and trustee must be notified of the amounts to be collected from the member based on the days in the month.

Example: In the same example above, the member has a $134.60 copayment remaining in the month of April to pay for services delivered by the provider. In May, the member has $92.42 remaining to pay for services delivered by the provider.

Failure to pay the required QIT copayment could result in termination of services. Refer to Section 3235, Refusal to Pay Qualified Income Trust Copayment.

 

3234 Qualified Income Trust Copayment Agreement

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) completes Form 1578, Qualified Income Trust (QIT) Copayment Agreement, and documents the:

  • service purchased;
  • amount available for copayment;
  • unit rate;
  • units purchased; and
  • monthly copayment amount for the specific services.

The units to be purchased must be converted to a monthly amount if that service is not already reported in a monthly format. The monthly copayment amount cannot exceed the total amount for that service for a month. If there are additional copayment funds after the first service is calculated, the copayment is applied to a second (or third) service, if necessary. For persons residing in adult foster care (AFC) or assisted living (AL) settings, the copayment amount is usually applied to the cost of AFC or AL. If copayment funds remain after being applied to the cost of AFC or AL, the remaining funds must be applied to other services such as nursing, personal assistance services (PAS) or medical supplies. For persons at home, the copayment is first used to purchase PAS, nursing or medical supplies.

Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, Form H2060-B, Needs Assessment Addendum, or other individual service plan (ISP) attachments should not be modified since the total number of units to be delivered is not changed by the copayment.

 

3234.1 Calculation Example and Completion of Form 1578

Revision 18-2; Effective September 3, 2018

 

There are 1,400 units (hours) of personal assistance services (PAS) included in the initial individual service plan (ISP). The available copayment amount is $1,250, and divided by $10.86 (PAS hourly rate) it equals 115.101 units; rounded down to the next lower half unit equals 115. (If the units were 115.633, it would be rounded down to 115.5.) On Form 1578, Qualified Income Trust (QIT) Copayment Agreement, in the Service Purchased by QIT Copayment column, enter PAS; in the Monthly Copayment Amount Available column, enter $1,250; in the Unit Rate column, enter 115 units; and in the Monthly Copayment Amount for Units Purchased, enter $1,248.90 (115 units multiplied by $10.86).

Next, calculate the annual amount of units to be purchased through QIT by multiplying the monthly units by 12. For example, 115 units multiplied by 12 months equals 1,380 annual units to be purchased through QIT. Subtract this amount from the total authorization to determine the units to be authorized on the adjusted Form H1700-1, Individual Service Plan (Pg. 1). For example, 1,400 units minus 1,380 equals 20 units of PAS to enter on the adjusted ISP.

After determining the amount of copayment to be paid to the service provider(s), the managed care organization (MCO) discusses the copayment with the applicant or member and the trustee of the trust. After explaining the requirements, the applicant, member, or authorized representative (AR) and the trustee must sign Form 1578. A copy of the signed agreement is given to the applicant, member and/or AR and the trustee.

Services cannot begin until Form 1578 is signed, indicating the applicant's or member's agreement to pay the required copayment. A copy of Form 1578 is sent to the service provider(s) along with the ISP. If an applicant or member refuses to sign the adjusted ISP or the copayment agreement, services are denied for failure to pay the required copayment.

 

3235 Refusal to Pay Qualified Income Trust Copayment

Revision 18-2; Effective September 3, 2018

 

The trustee of the Qualified Income Trust (QIT) must pay the QIT copayment directly to the provider by the 10th day of the month, or not later than 10 days after STAR+PLUS Home and Community Based Services (HCBS) program services have started in situations when services did not start on the first day of the month.

If the trustee refuses to pay the copayment for services, the provider must notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, within two business days. The MCO must contact the trustee to learn the reason for refusal to pay. The MCO must also:

  • write a letter to the member and the trustee explaining the consequences of continued failure to pay; and
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the trustee has refused to make the copayment.

If the copayment is not fully paid within 30 days of the due date, the MCO initiates denial.

If the Home and Community Support Services (HCSS) provider does not deliver sufficient services to use the copayment amount, the HCSS provider must refund any remaining copayment to the trustee and notify the member and MCO via Form H2067-MC.

Example: The provider collected a $400 QIT copayment to purchase 36.5 hours of PAS, but only 15 hours were delivered because the member went out of town. The provider must refund the dollar amount difference between 36.5 hours and 15 hours. The MCO must notify the MEPD specialist of the refund.

Refer to Section 7100, Adult Foster Care, for procedures related to failure to pay copayment.

 

3236 Copayment and Room and Board

Revision 19-1; Effective June 3, 2019

 

Members who are determined to be financially eligible based on the special medical assistance only (MAO) institutional income limit may be required to share in the cost of STAR+PLUS Home and Community Based Services (HCBS) program services. The method for determining the member's copayment is documented on the Medicaid for the Elderly and People with Disabilities (MEPD) copayment worksheet for the STAR+PLUS HCBS program.

The copayment amount is the member's remaining income after all allowable expenses have been deducted. The copayment amount is applied only to the cost of services funded through the STAR+PLUS HCBS program and specified on the member's individual service plan (ISP). The copayment must not exceed the cost of services actually delivered. Members must pay the cost-sharing amount directly to the provider contracted to deliver authorized STAR+PLUS HCBS program services.

Refer to Appendix XIII, Your Financial Rights in an Assisted Living Facility STAR+PLUS, for additional information.

To determine the room and board amounts for members residing in adult foster care (AFC) or assisted living (AL) settings, apply the following post-eligibility calculations:

  • for individuals, the room and board amount is the Supplemental Security Income (SSI) federal benefit rate (FBR) minus the personal needs allowance;
  • for SSI couples, the room and board amount is the SSI FBR [for a couple] minus the personal needs allowance for an individual multiplied by two; or
  • for couples with incomes that exceed the SSI FBR for couples, the room and board amount is the couple's income minus the personal needs allowance for an individual multiplied by two. This amount cannot exceed double the room and board amount for an individual.

Some individuals will be responsible for contributing toward the cost of STAR+PLUS HCBS program services. This is referred to as copayment and/or room and board charges. The copayment amount is not a factor in determining the individual's eligibility for services.

The MEPD specialist calculates the copayment and deducts allowable incurred medical expenses for individuals whose eligibility is based on the special institutional income limits, or for individuals who have a qualified income trust (QIT). Refer to Section 3123, Incurred Medical Expenses, and Appendix XXII, §1915(c) Waiver Program Co-Payment Worksheets, of the MEPD Handbook.

SSI recipients, including SSI recipients who also receive Retirement, Survivors and Disability Insurance, are not required to make a copayment and no copayment calculation is necessary for them. STAR+PLUS HCBS program members who reside in AFC or AL settings may be required to pay a copayment.

The managed care organization (MCO) must clearly explain to the applicant, if it is determined the applicant must pay a monthly copayment that the copayment amount must be paid directly to the AL or AFC provider. All STAR+PLUS HCBS program members, including SSI recipients, are required to pay room and board in AFC and AL settings.

The MCO must also explain to the member that the member is required to pay the AFC or AL provider a room and board charge. If the member fails to pay the agreed-upon room and board charge and/or copayment, the member could be terminated from the STAR+PLUS HCBS program.

Program Support Unit (PSU) staff notify the member and MCO of new copayment amounts to be collected on Form H2065-D, Notification of Managed Care Program Services.

Refer to Section 3232, Payments from the Qualified Income Trust, and Section 3234, Qualified Income Trust Copayment Agreement, for specific QIT copayment procedures.

 

3237 Determining Room and Board Charges

Revision 18-2; Effective September 3, 2018

 

All STAR+PLUS Home and Community Based Services (HCBS) program members must pay the room and board charges to be eligible for assisted living (AL). Room and board cannot be waived, but an AL facility (ALF) may choose to accept an individual for a lower amount. STAR+PLUS HCBS program policy does not direct the facility to accept or reject the individual.

The room and board charge for an individual is fixed at the amount remaining after subtracting $85 from the Supplemental Security Income (SSI) federal benefit rate (FBR). FBR current amounts are found in Appendix VIII, Monthly Income/Resource Limits, which is updated when the FBR changes.

For couples where both partners are residing in an adult foster care (AFC) or AL settings, $170 is subtracted from the couple's income so each member of the couple keeps $85 a month for personal needs and the remainder is the room and board charge for the couple. Due to the difference in income between couples and individuals, the amount of room and board charge for a couple depends on income.

  • For SSI couples, the room and board charge is the FBR for a couple minus the $170 personal needs allowance.
  • For couples who are not SSI recipients, but whose income is less than the current FBR for an individual doubled, the room and board charge is for the monthly income minus the $170 for personal needs.
  • For couples whose income exceeds twice the SSI FBR for an individual, the full room and board charge for two individuals is required.

The AFC or AL participant will keep $85 a month for personal needs.

 

3238 Determining Copayment Amounts

Revision 19-1; Effective June 3, 2019

 

After determining financial eligibility for Medicaid, Medicaid for the Elderly and People with Disabilities (MEPD) specialists determine the amount of money available for copayment. MEPD specialists send Form H2067-MC, Managed Care Programs Communication, or Form H1746-A, MEPD Referral Cover Sheet, and a copy of the completed MEPD Waiver Program Copayment Worksheet to Program Support Unit (PSU) staff indicating the amount available for the monthly ongoing copayment. PSU staff forward this information to the managed care organization (MCO) by uploading Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral.

 

3239 Copayment Changes

Revision 19-1; Effective June 3, 2019

 

A member's copayment may change during the time he is receiving the STAR+PLUS Home and Community Based Services (HCBS) program, typically due to a change in income or medical expenses. Copayment changes must always be effective on the first day of the month. If the copayment is increasing, Program Support Unit (PSU) staff must send the member and managed care organization (MCO) notification on Form H2065-D, Notification of Managed Care Program Services, and the increase is effective the first day of the month after the expiration of the adverse action period. The MCO is responsible for notifying the provider.

If the first day of the month occurs before the end of the adverse action period, the copayment increase is effective the first day of the subsequent month. Decreases in copayment require Form H2065-D notification, but can be effective the first day of the month after the notification is sent.

Copayments may also change due to other circumstances. Medicaid for the Elderly and People with Disabilities (MEPD) specialists are responsible for calculating and handling fraud referrals. Notices and letters on these issues are prepared by MEPD specialists with copies to PSU staff. MEPD specialists inform PSU staff of fraud referrals and determine whether any corrections are necessary to the member's copayment based on a change in the amount available for copayment. PSU staff upload Form H2067-MC, Managed Care Programs Communication, to inform the MCO of any change in the copayment amount.

Underpayments by the member that are not part of a fraud referral, such as those based on reconciliation of variable income, result in the MEPD specialist sending a letter to the member requesting that the member pay the MCO the amount of copayment that was underpaid. PSU staff are not responsible for determining if the underpayment is made to the MCO. The underpayment is not retroactively considered in the copayment calculation. The MEPD specialist notifies PSU staff if the ongoing copayment amount increases to the appropriate mailbox designated for the MEPD specialist to submit to PSU staff through the MEPD Communications Tool. If the amount does increase, PSU staff must upload Form H2065-D to TxMedCentral in the MCO’s SPW folder, notifying the MCO of the increase in the monthly copayment amount. The increase in copayment is effective the first day of the month after the expiration of the adverse action period indicated on Form H2065-D.

Refunds due to the member require a new copayment calculation be completed. The copayment may be calculated to allow the refund to be deducted from the member's next copayment amount due to the provider or the member may be given a reimbursement by the adult foster care/assisted living (AFC/AL) provider if there are no future copayments. The MCO determines if the AFC/AL provider should submit a negative billing. The effective date of the decrease in copayment is the first of the month after Form H2065-D is sent.

Example: The member's ongoing copayment is $100 per month. The MEPD specialist determines a copayment amount of $75 should have been effective February 1. A refund of $25 per month for the months of February, March, April and May total $100. PSU staff find out about the new amount on May 20 and immediately upload Form H2065-D notifying the MCO. The MCO contacts the provider of the member's new copayment amounts: June – $0, July – $50, August – $75, ongoing.

 

3240 STAR+PLUS Home and Community Based Services Program Requirements

Revision 18-2; Effective September 3, 2018

 

The STAR+PLUS Home and Community Based Services (HCBS) program is provided by virtue of 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 STAR+PLUS HCBS program, the following criteria must be met:

  • medical necessity (MN) (see Section 3241, Medical Necessity Determination);
  • services under the established cost limits (see Section 3242.1, Maximum Limit);
  • the member's unmet need for at least one STAR+PLUS HCBS program (see Section 3242.2, Unmet Need for at Least One Waiver Service); and
  • full Medicaid coverage.

 

3241 Medical Necessity Determination

Revision 18-2; Effective September 3, 2018

 

A STAR+PLUS Home and Community Based Services (HCBS) program applicant or member must have a valid medical necessity (MN) determination before admission into the STAR+PLUS HCBS program. The determination of MN is based on a completed Medical Necessity and Level of Care (MN/LOC) Assessment. The applicant's or member's individual service plan (ISP) cost limit is calculated based on the MN/LOC Assessment information.

The managed care organization (MCO) completes and submits MN/LOC Assessments to Texas Medicaid & Healthcare Partnership (TMHP) for STAR+PLUS HCBS program applicants or members. TMHP processes MN/LOC Assessments for applicants or members to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in the STAR+PLUS HCBS program to:

  • categorize needs for applicants or members; and
  • establish the ISP cost limit.

When TMHP processes an MN/LOC Assessment, a three-alphanumeric digit RUG appears in the Level of Service record in the Service Authorization System Online (SASO) and in the TMHP Long Term Care (LTC) Online Portal. An MN/LOC Assessment with incomplete information will result with a BC1 code instead of a RUG value. An MN/LOC Assessment resulting with a BC1 code does not have all of the information necessary for TMHP to accurately calculate a RUG for the member. Code BC1 is not a valid RUG to determine STAR+PLUS HCBS program eligibility.

The MCO nurse must correct the information on the MN/LOC Assessment within 14 days of submitting the assessment that resulted in a BC1 code. After 14 days, the MCO nurse must inactivate the MN/LOC Assessment and resubmit the assessment with correct information to TMHP.

For applicants or members needing a Medicaid eligibility financial decision, Program Support Unit (PSU) staff must notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist that the applicant or member meets MN. This notification can be by telephone or may be documented on Form H1746-A, MEPD Referral Cover Sheet, which PSU staff send to the MEPD specialist. The MEPD specialist may view the SASO or LTC Online Portal to confirm that the applicant or member has met the MN criteria.

 

3241.1 Medical Necessity Determination for Applicants Residing in Nursing Facilities

Revision 19-1; Effective June 3, 2019

 

During the initial contact with the applicant or member, Program Support Unit (PSU) staff must explore the applicant's or member's status in the nursing facility (NF) and determine whether the applicant or member has a current medical necessity (MN). This information helps determine whether the managed care organization (MCO) should complete the Medical Necessity and Level of Care (MN/LOC) Assessment. Communication with the NF regarding plans for submittal of the MN/LOC Assessment may be necessary. PSU staff must make every effort to determine if authorizing the MCO to complete the MN/LOC Assessment is necessary and to avoid duplication of submittal to Texas Medicaid & Healthcare and Partnership (TMHP) for an MN determination.

Approved MNs for NF residents may be verified through the Service Authorization System Online (SASO). In this situation, the MCO must not complete a new MN/LOC Assessment. The MN on record will be accepted as a valid MN. The MCO should ask the NF for a courtesy copy of the Minimum Data Set (MDS) completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.

If an applicant or member is applying for Medicaid as a resident in the NF and is concurrently applying for the STAR+PLUS Home and Community Based Services (HCBS) program, the NF should complete the MDS. The MCO is instructed not to complete a new MN/LOC Assessment with the pre-enrollment assessment. PSU staff must notify the MCO that MN exists by entering the Resource Utilization Group (RUG) and expiration date in Section A, Item 6, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization. If the NF refuses to complete the MDS in a timely manner, PSU staff must authorize the MCO to complete the MN/LOC Assessment on the applicant or member by entering N/A in Section A, Item 6, of Form H3676 and uploading to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention.

A different situation exists when a STAR+PLUS HCBS program applicant or member enters the NF on Medicare. PSU staff must authorize the MCO to complete the MN/LOC Assessment, as described above, to expedite receiving an MN and avoid a delay for the applicant's or member's return to the community.

A denied MN decision resulting from an MN/LOC Assessment the MCO submitted is not used to deny a STAR+PLUS HCBS program applicant who has a current valid NF MDS. The NF MDS and RUG are used in the STAR+PLUS HCBS program eligibility determination.

An 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 end date and must have an active MN period covering the entire ISP period. The MN/LOC Assessment end date must be adjusted to match the ISP end date, if necessary.

 

3241.2 Medical Necessity Determination for Applicants Not Residing in Nursing Facilities

Revision 18-2; Effective September 3, 2018

 

For STAR+PLUS Home and Community Based Services (HCBS) program applicants not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the Medical Necessity and Level of Care (MN/LOC) Assessment completed by the managed care organization (MCO) doing the pre-enrollment home health assessment.

The MCO must electronically submit the MN/LOC Assessment to TMHP after it has been signed by the physician. A copy of the MN/LOC Assessment is filed in the member's case file.

 

3242 Individual Cost Limit Requirement

Revision 18-2; Effective September 3, 2018

 

 

3242.1 Maximum Limit

Revision 17-1; Effective March 1, 2017

 

The cost of the STAR+PLUS Home and Community Based Services (HCBS) program cannot exceed 202 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the STAR+PLUS HCBS program applicant must have an individual service plan (ISP) developed that is at or below 202 percent of what it would cost to provide services in an NF.

For initial applications, the total cost of services for an applicant's ISP must be equal to or below the individual's ISP cost limit. Applicants exceeding the cost limit cannot elect to receive reduced services for entry to the program if this would pose a risk to the individual's health, safety and welfare.

 

3242.2 Unmet Need for at Least One STAR+PLUS Home and Community Based Services Program Service

Revision 21-2; Effective August 1, 2021

 

The Code of Federal Regulations (CFR) specifies individuals are not eligible to receive the STAR+PLUS Home and Community Based Services (HCBS) program unless they have a need for at least one STAR+PLUS HCBS program service. Therefore, the Texas Health and Human Services Commission (HHSC) cannot approve any individual service plan (ISP) which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form H1700-1, Individual Service Plan. When Program Support Unit (PSU) staff receive an ISP from the managed care organization (MCO) with a $0.00 STAR+PLUS HCBS program cost, the following activities occur.

Within two business days:

PSU staff upload Form H2067-MC, Managed Care Programs Communication, to the appropriate XXXSPW folder in TxMedCentral, using the appropriate naming convention. This will inform the MCO to verify if the ISP, which has no services, is accurate.

  • If the ISP was submitted incorrectly:
    • the MCO must resubmit a corrected ISP within two business days (for example, the ISP uploaded correctly but is missing services); and
    • PSU staff must honor the original postdate if the MCO uploads the corrected ISP within two business days of notification by PSU staff; or
  • If the ISP was submitted correctly:
    • the MCO must upload Form H2067-MC informing PSU the ISP reflects the member's needs; and
    • PSU staff:
      • begin denial procedures for these cases by completing Form H2065-D, Notification of Managed Care Program Services;
      • mail the original Form H2065-D to the member; and
      • upload Form H2065-D TxMedCentral in the XXXSPW folder, using the appropriate naming convention.

 

3300 Administrative Procedures

Revision 19-1; Effective June 3, 2019

 

Program Support Unit (PSU) staff operate in each Texas Health and Human Services Commission (HHSC) STAR+PLUS managed care service area. PSU staff provide support necessary for the coordination of long-term services and supports (LTSS), including the STAR+PLUS Home and Community Based Services (HCBS) program, for members who transfer in and out of STAR+PLUS service areas. PSU staff are also the point of contact for the coordination and monitoring of members transitioning from:

  • nursing facilities (NFs) to the community, and
  • the Medically Dependent Children Program (MDCP) to the STAR+PLUS HCBS program.

Responsibilities of PSU staff include:

  • acting as an intermediary in relaying communications between Community Care Services Eligibility (CCSE) staff and the managed care organization (MCO);
  • receiving requests for services from CCSE staff performing intake tasks;
  • coordinating the application process for the STAR+PLUS HCBS program for NF residents who wish to transition to the community;
  • assisting applicants with enrollment through the enrollment broker to select an MCO and primary care provider (PCP), if necessary;
  • coordinating with Medicaid for the Elderly and People with Disabilities (MEPD) specialists regarding Medicaid eligibility, as appropriate;
  • sending service authorizations (Form H3676, Managed Care Pre-Enrollment Assessment Authorization) to the MCO to do STAR+PLUS HCBS program assessments for non-members;
  • serving as the primary contact for transitions in and out of STAR+PLUS service areas;
  • assisting CCSE case managers in processing applications for non-Medicaid services by verifying the MCO denied the equivalent service under STAR+PLUS (see Section 3510, Money Follows the Person and Managed Care);
  • assisting MCO members requesting placement on an interest list for services excluded from managed care (see Section 3222, Excluded Groups);
  • removing members in STAR+PLUS counties from the STAR+PLUS HCBS program interest list and processing their applications;
  • assisting members who are aging out of MDCP and/or Texas Health Steps/Comprehensive Care Program in transferring to the STAR+PLUS HCBS program (see Section 3420, Individuals Aging Out of Children's Programs);
  • coordinating continuity of care for members suspended or disenrolled from STAR+PLUS;
  • approving the STAR+PLUS HCBS program based upon eligibility;
  • making Service Authorization System Online (SASO) entries as required for actions involving STAR+PLUS HCBS program members;
  • handling the administrative claims process;
  • researching and requesting disenrollment when the member is enrolled inappropriately;
  • denying eligibility for the STAR+PLUS HCBS program; and
  • handling requests for Medicaid fair hearings for applicants or members who are denied STAR+PLUS HCBS program eligibility.

 

3310 Intake and Enrollment

Revision 19-1; Effective June 3, 2019

 

When Community Care Services Eligibility (CCSE) receives a request for the STAR+PLUS Home and Community Based Services (HCBS) program, CCSE intake staff must assess whether the request for services should be forwarded for processing to the:

  • appropriate Texas Health and Human Services Commission (HHSC) unit;
  • HHSC enrollment broker;
  • Program Support Unit (PSU) staff; or
  • appropriate managed care organization (MCO).

Use the chart below to determine how to process requests for services in STAR+PLUS.

Type of Individual Enrolled with a STAR+PLUS MCO? How does CCSE handle this request?
Full Medicaid recipient applying for the STAR+PLUS HCBS program No. Forward the intake request to the enrollment broker. Supplemental Security Income (SSI) or other full Medicaid program recipients never go on the STAR+PLUS HCBS program interest list, whether they are enrolled with STAR+PLUS or not.

The enrollment broker determines what is preventing MCO enrollment and takes action to resolve the issue, which may include referral to the Health and Human Services Commission (HHSC) or contact with the individual.

Full Medicaid recipient applying for the STAR+PLUS HCBS program Yes. Refer the recipient to the MCO for the STAR+PLUS HCBS program. This individual will never go on the interest list.
Medically Dependent Children Program (MDCP) member who is turning age 21 No. MDCP is excluded from STAR+PLUS. A quarterly report is emailed to the PSU supervisor identifying individuals who are turning age 21 within the next 18 months and who receive MDCP and/or PDN. See the procedures for transition from MDCP to the STAR+PLUS HCBS program in Section 3420, Individuals Aging Out of Children's Programs. These individuals never go on the interest list.
Medical assistance only (MAO) applicant for the STAR+PLUS HCBS program No. Staff receiving the intake will place the individual on the STAR+PLUS HCBS program interest list.
Nursing facility NF resident applying for the STAR+PLUS HCBS program Yes. The resident must be referred to the MCO for an upgrade to the STAR+PLUS HCBS program.
NF resident applying for the STAR+PLUS HCBS program No. All Money Follows the Person (MFP) individuals are placed on the interest list by intake staff and immediately assigned. The community services interest list (CSIL) assignment automatically generates an email notifying PSU staff of the referral.

When CCSE intake staff determine a request for the STAR+PLUS HCBS program should be forwarded to PSU staff for processing, they must submit an email to HHSC Star Plus Waiver Interest List.

The email should contain the following data elements:

  • Name;
  • Social Security number (SSN);
  • Address;
  • Contact phone number;
  • Date of birth;
  • Medicaid identification (ID) number, if applicable; and
  • County of residence.

If CCSE intake staff are unable to obtain all data elements from the applicant, the referral will still be processed by PSU staff so that access to the STAR+PLUS HCBS program interest list will not be denied. Although CCSE intake staff routinely provides the initial four demographic data, there may be times when an individual requesting services is unable to furnish the date of birth. If this information is not included in the referral, PSU staff must obtain it as the date of birth is required for entry to the Community Services Interest List (CSIL) system.

PSU state office staff will monitor the interest list mailbox and process the referrals within three business days by placing the individual on the STAR+PLUS HCBS program interest list, using the original date CCSE intake staff referred the request to PSU staff.

Because of member choice issues, MCOs are prohibited from contacting non-members without the authorization from PSU staff to complete required HCBS assessments. For MDCP members aging out, individuals on the STAR+PLUS HCBS program interest list, or MFP and MFP Demonstration initiative individuals, PSU staff:

  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
  • upload Form H3676 in the XXXSPW folder to TxMedCentral in the MCO folder, following the naming convention instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance.

Note: When PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) for enrollment, the designation on the Individual – Managed Care screen of “Candidate Eligible” is not verification of enrollment. When enrollment is complete, the Individual – Managed Care screen will display “Enrolled.”

Note: CCSE intake screeners must provide information about the Program of All-Inclusive Care for the Elderly (PACE) to individuals during the intake and referral process when the individual requesting services is determined to be age 55 years or older and resides in a PACE service area. PACE services are available in designated areas of El Paso, Amarillo/Canyon and Lubbock.

CCSE intake screeners must be aware of the PACE service areas and referral procedures. Additional information on PACE can be found at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/program-all-inclusive-care-elderly-pace.

 

3311 Interim Services for Individuals Awaiting Managed Care Enrollment

Revision 18-2; Effective September 3, 2018

 

While awaiting enrollment in managed care, individuals are entitled to receive services from the Community Care for Aged and Disabled (CCAD) program. Referrals to CCAD must be made for all full Medicaid recipients. Case managers may assess these individuals for services if it appears services can be authorized and delivered prior to enrollment.

 

3311.1 Earliest Date for Adding a Member Back to the Interest List

 

Revision 19-1; Effective June 3, 2019

 

The earliest date an applicant or member may be added back to the Community Services Interest List (CSIL) database for the same program the applicant is denied is the date the applicant is determined to be ineligible for the program (for applicants) or (for STAR+PLUS Home and Community Based Services (HCBS) program members), the first date the applicant or member is no longer eligible for the program denied.

Example 1: The applicant is released from the STAR+PLUS HCBS program CSIL on March 2, 2019. The case manager determines the applicant is not eligible for STAR+PLUS HCBS program on March 28, 2019, and sends notification to the applicant of ineligibility. The first date the denied applicant can be added back to the STAR+PLUS HCBS program interest list is March 28, 2019.

Example 2: A STAR+PLUS HCBS program member is determined not eligible on March 28, 2019, and PSU staff send notification to the STAR+PLUS HCBS program member of termination of benefits. Termination is effective April 30. The first date the denied member can be added back to the STAR+PLUS HCBS program interest list is May 1, 2019.

If the applicant's or STAR+PLUS HCBS program member’s name is added back to the interest list prior to the last date of program eligibility, the CSIL database interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program.

Example 3: A member's STAR+PLUS HCBS program services are denied due to medical necessity (MN) and end on March 30, 2019. The first date the member can be added back to the STAR+PLUS HCBS program interest list is April 1, 2019.

Example 4: A member's STAR+PLUS HCBS program services are denied and will end March 13, 2019. The first date the member can be added back to the STAR+PLUS HCBS program interest list is March 14, 2019. If the member is already on another interest list, the denial date for the STAR+PLUS HCBS program would not impact the member's original date on the other interest list.

 

3312 Enrollment

Revision 19-1; Effective June 3, 2019

 

The enrollment broker mails enrollment packets to all Medicaid recipients who are candidates for STAR+PLUS. This packet contains information about STAR+PLUS, instructions for completing the enrollment form and information about the available STAR+PLUS managed care organizations (MCOs) from which the recipient can choose. Recipients can return enrollment forms via mail, complete an enrollment form at an enrollment event or presentation, or call the enrollment broker and enroll via telephone at 1-800-964-2777.

Recipients have 30 days after receiving an enrollment packet to select an MCO. If a selection is not made within 30 days, the recipient will be assigned to an MCO and a primary care provider (PCP). Failure to choose an MCO could lead to delays in services or default assignment to an MCO. Recipient assignments to an MCO or PCP are automatic, using a default process. Recipients assigned through the default process may still make a choice about their STAR+PLUS MCO and PCP after they have been enrolled at least one month. However, he or she must receive Medicaid services through the assigned MCO and PCP until they contact the MCO or the enrollment broker at 1-800-964-2777 to request a change.

Failure to select a PCP may delay services when a physician's order or medical necessity (MN) determination is required.

 

3312.1 Enrollment Procedures Following Release from the Interest List

Revision 21-2; Effective August 1, 2021

 

Within 14 days of release from the interest list (see Section 3311.1, Interest List Procedures),  Program Support Unit (PSU) staff take the following steps to ensure candidates are successfully enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program.

PSU staff contact the applicant or authorized representative (AR) to:

  • give a general description of STAR+PLUS HCBS program services;
  • provide a list of managed care organizations (MCOs) and encourage the member to contact one for service information;
  • discuss the importance of choosing an MCO so assessments and initial individual service plans (ISPs) can be completed timely in order to avoid a delay in eligibility determination for the STAR+PLUS HCBS program; and
  • inform the individual the MCO in which he or she enrolls can be changed at any time after the first month of service.

The applicant chooses an MCO and notifies PSU staff verbally or in writing.

Within two business days of the MCO selection, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload it on TxMedCentral in the MCO's SPW folder, following the naming convention instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance.

The MCO completes:

  • Section B of Form H3676;
  • a Medical Necessity and Level of Care (MN/LOC) Assessment;
  • Form H1700-1, Individual Service Plan; and
  • Form H1700-3, Individual Service Plan – Signature Page.

Note: The Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. The MCO has 45 days per UMCC requirement to complete all assessments and submit the results via Form H3676, Part B, to PSU staff.

The MCO uploads the STAR+PLUS HCBS program ISP to TxMedCentral in the MCO's ISP folder, following the naming instructions in Section 5110. The MCO uploads Form H3676 to TxMedCentral in the SPW folder, following instructions in Section 5110.

If the MCO does not upload an ISP within 45 days after PSU staff uploaded Form H3676, Part A, PSU staff notify by email the Managed Care Compliance & Operations (MCCO) staff assigned to the MCO.

Within five business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff verify eligibility based on Medicaid eligibility, medical necessity and level of care (MN/LOC), and an ISP cost within the individual's assessed cost limit based on the established Resource Utilization Group value.

The start of care (SOC) date for the STAR+PLUS HCBS program is the first day of the month following receipt of the latter of:

  • MN/LOC;
  • ISP; and
  • Medicaid eligibility.

Example: MN/LOC is received at Texas Medicaid & Healthcare Partnership (TMHP) on May 15, the ISP is uploaded to TxMedCentral on June 2, and Medicaid eligibility is effective May 1. The SOC date is July 1.

The SOC date is the same as the ISP begin date, and will always be the first day of the month. Because individuals are not eligible for any STAR+PLUS HCBS program benefits between the notification form signature date and the ISP begin date, PSU staff must take care in recording the correct date on the notification to the member.

If eligibility is approved, PSU staff complete Form H2065-D, and:

  • mail the original to the applicant;
  • upload the form on TxMedCentral in the MCO's SPW folder, following the instructions in Section 5110;
  • fax or mail a copy to the MEPD specialist; and
  • notify Enrollment Resolution Services (ERS) by email

If eligibility is denied, PSU staff complete Form H2065-D and:

  • mail the original to the applicant;
  • upload it on TxMedCentral in the MCO's SPW folder, following the instructions in Section 5110; and
  • fax or email a copy to the MEPD specialist.

PSU staff make Service Authorization System Online (SASO) entries following procedures in the SAS Help File within five business days of receipt of all required eligibility verification.

After the individual has been determined eligible for the STAR+PLUS HCBS program, ERS updates the member's TIERS record to indicate managed care enrollment.

 

3313 Termination of CCAD Services Upon STAR+PLUS Home and Community Based Services Program Enrollment

Revision 19-1; Effective June 3, 2019

 

Code of Federal Regulations (CFR) §431.213 Exceptions from advance notice.

The agency may mail a notice not later than the date of action if —

(a) The agency has factual information confirming the death of a recipient;

(b) The agency receives a clear written statement signed by a recipient that —

(1) He no longer wishes services; or

(2) Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;

(c) The recipient has been admitted to an institution where he is ineligible under the plan for further services;

(d) The recipient's whereabouts are unknown and the post office returns agency mail directed to her or him indicating no forwarding address (See §431.231 (d) of this subpart for procedure if the recipient's whereabouts become known);

(e) The agency establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

(f) A change in the level of medical care is prescribed by the recipient's physician.

Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the Community Care Services Eligibility (CCSE) case manager so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service. The STAR+PLUS Home and Community Based Services (HCBS) program member must be encouraged to contact the managed care organization (MCO) to request any services being denied that are not included in the STAR+PLUS HCBS program individual service plan (ISP).

The 10-day adverse action prior notice requirement does not apply to individuals transferring from CCAD or other waiver programs to the STAR+PLUS HCBS program.

 

3313.1 Procedure for STAR+PLUS Home and Community Based Services Program Applicants

Revision 19-1; Effective June 3, 2019

 

For individuals just entering the STAR+PLUS Home and Community Based Services (HCBS) program, Program Support Unit (PSU) staff must coordinate the termination of other waiver or Community Care for the Aged and Disabled (CCAD) services with the waiver or Community Care Services Eligibility (CCSE) case manager. This ensures the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

It is not necessary to provide an adverse action period prior to closing the authorization in the Service Authorization System Online (SASO).

CCAD services are terminated by the CCSE case manager no later than the day prior to STAR+PLUS HCBS program enrollment. This is crucial since no STAR+PLUS HCBS program individual may receive CCAD and STAR+PLUS HCBS program services on the same day. The CCSE case manager must send:

  • Form 2065-A, Notification of Community Care Services, denying ongoing Texas Health and Human Services Commission (HHSC) services; and
  • Form 2101, Authorization for Community Care Services, to the provider. Include a notation in the comments section that the individual is transferring to the STAR+PLUS HCBS program.

 

3313.2 Procedure for STAR+PLUS Home and Community Based Services Program Members

Revision 19-1; Effective June 3, 2019

 

If it is determined that an existing STAR+PLUS Home and Community Based Services (HCBS) program member is receiving any Service Group (SG) 7 Community Care for the Aged and Disabled (CCAD) services, Program Support Unit (PSU) staff must begin denial procedures for the SG 7 service immediately.

If CCAD services are authorized in SASO, the Community Care Services Eligibility (CCSE) case manager must immediately send:

  • Form 2065-A, Notification of Community Care Services, including a notation to the provider in the comments section that the individual is transferring to the STAR+PLUS HCBS program; and
  • Form 2101, Authorization for Community Care Services.

 

3314 Managed Care Organization Changes

Revision 18-2; Effective September 3, 2018

 

Members may change managed care organization (MCO) plans as often as monthly by contacting the enrollment broker at 1-800-964-2777. The enrollment broker makes plan changes based on the monthly cutoff periods, which occur around the middle of the month. Depending on which day of the month (before or after the enrollment broker cutoff), the plan change will either occur the first day of the next month or the month after. The change will show up on the 834-daily enrollment file notifying the MCO of the new member. The Program Support Unit (PSU), when notified by the member, state or an MCO that a member has elected to change MCOs, will update the Service Authorization System Online (SASO) to change the previous MCO to the new MCO.

 

3315 STAR+PLUS Home and Community Based Services Program Individuals Requesting Non-Managed Care Services

Revision 18-2; Effective September 3, 2018

 

Requirements of the STAR+PLUS Home and Community Based Services (HCBS) program provide all of the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program member. STAR+PLUS HCBS program member requesting additional services must be referred to the managed care organization's service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

 

3315.1 Requests from Individuals Awaiting Managed Care Enrollment

Revision 18-2; Effective September 3, 2018

 

Individuals awaiting managed care enrollment may be assessed for interim Community Care for the Aged and Disabled (CCAD) services. Texas Health and Human Services Commission (HHSC) case managers may assess all individuals whose managed care enrollment is pending if it appears CCAD services can be approved and delivered prior to enrollment in managed care.

 

3315.2 Requests from STAR+PLUS Home and Community Based Services Program Members

Revision 18-2; Effective September 3, 2018

 

Requirements of the federal 1115 waiver dictate that the STAR+PLUS Home and Community Based Service (HCBS) program provide the services (excluding hospice) needed to enable the member to live safely in the community. Therefore, non-managed care services cannot be authorized for STAR+PLUS HCBS program members. STAR+PLUS HCBS program members requesting additional services must be referred to the managed care organization's (MCO's) service coordinator.

Hospice services may be authorized along with STAR+PLUS services or the STAR+PLUS HCBS program.

 

3315.3 Requests from STAR+PLUS Services Members

Revision 19-1; Effective June 3, 2019

 

When a STAR+PLUS services managed care member requests non-Medicaid services, Texas Health and Human Services Commission (HHSC) staff must first determine if there is a slot available for the requested service. If not, the individual's name is added to the appropriate interest list by entering the information in the Community Services Interest List (CSIL) system. Members are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for services become available.

When a slot is available, or before release from the interest list, HHSC staff consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual is a STAR+PLUS member (see Section 5130, Managed Care Data in TIERS). If it is determined that the individual is a STAR+PLUS member, intake staff must contact Program Support Unit (PSU) staff before assignment to a case manager to determine if the managed care organization (MCO) is already delivering the managed care version of the requested service.

Within two business days of contact by intake staff, PSU staff:

  • contact the appropriate MCO by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO XXXSPW folder using the appropriate naming convention. Form H2067-MC must contain:
    • the individual's name;
    • Medicaid number identification (ID); and
    • a request to determine if service is already being delivered; and
  • follow up by phone every five business days until a response is received from the MCO.

Within five business days of receiving uploaded Form H2067-MC, the MCO must respond to PSU staff by uploading Form H2067-MC to the XXXSPW folder in TxMedCentral using the appropriate naming convention.

Within two business days of receipt of the MCO's response, PSU staff must notify the referring HHSC staff by email or with Form H2067-MC.

If PSU staff determine the requested service is not being delivered by the MCO, the intake must be assigned to a case manager. The case manager processes the application and authorizes services if all eligibility criteria are met.

The PSU staff's response must be included in materials forwarded to the case manager at the time of case assignment. How the case manager proceeds with the eligibility determination process depends on the PSU's documented response.

If PSU staff determine the requested service is already being delivered by the MCO, PSU staff inform the member of the MCO's response. The member is urged to consult the MCO if he or she disagrees or feels the services are not sufficient to meet her or his needs.

See Section 3310, Intake and Enrollment, for additional information on intake and referral procedures.

 

3316 Requests for STAR+PLUS Home and Community Based Services Program from Participants in 1915(c) Medicaid Waivers

Revision 21-2; Effective August 1, 2021

 

Participants in 1915(c) Medicaid waivers may request an assessment for the STAR+PLUS Home and Community Based Services (HCBS) program at any time if they:

  • have Supplemental Security Income (SSI) Medicaid or another full Medicaid program; or
  • are medical assistance only (MAO).

When a 1915(c) Medicaid waiver recipient requests the STAR+PLUS HCBS program through the Texas Health and Human Services Commission (HHSC), a referral is made to Program Support Unit (PSU) staff.

PSU staff are responsible for completing the following activities within 14 days of the initial request for a STAR+PLUS HCBS program assessment. All attempted contacts with the member or encountered delays must be documented. PSU staff:

  • move the individual to the top of the STAR+PLUS HCBS program interest list with an "assessment requested" notation;
  • contact the STAR+PLUS HCBS program member and explain STAR+PLUS HCBS program services; and
  • send a copy of the regional STAR+PLUS managed care organization (MCO) provider directories and comparison chart to the 1915(c) Waiver recipient.

Within two business days of notification of the MCO selection by the STAR+PLUS HCBS program applicant, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and uploads it in the XXXSPW folder on TxMedCentral, using the appropriate naming convention.

The MCO completes:

  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, as appropriate;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum, as applicable;
  • medical necessity and level of care (MC/LOC);
  • Section B of Form H3676;
  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum; and
  • Form H1700-3, Individual Service Plan – Signature Page.

The MCO uploads Form H1700-1, Form H1700-3, and Form H3676 in the XXXSPW folder on TxMedCentral using the appropriate naming convention. If the packet from the MCO is not received within 45 days after the assessment is authorized, PSU staff email Managed Care Compliance & Operations (MCCO) as notification of the time frame for completing the individual service plan (ISP) was not met.

Within two business days of receipt of all required STAR+PLUS HCBS program eligibility documentation, PSU staff determine STAR+PLUS HCBS program eligibility based upon medical necessity, and an ISP cost within the Resource Utilization Group (RUG) cost limit.

If eligibility for the STAR+PLUS HCBS program is denied or the applicant decides not to accept the STAR+PLUS HCBS program, PSU staff complete Form H2065-D, Notification of Managed Care Program Services, and:

  • mail the original to the 1915(c) Medicaid waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving; and
  • notify the MCO by uploading a copy to TxMedCentral.

If eligibility is approved and the individual chooses to accept STAR+PLUS HCBS program services, the individual is enrolled in the STAR+PLUS HCBS program the first day of the next month.

Within two business days of determining the start of care date for the STAR+PLUS HCBS program, PSU staff complete Form H2065-D and:

  • mail the original to the 1915(c) Medicaid waiver recipient;
  • notify the MCO by uploading a copy to TxMedCentral; and
  • notify Enrollment Resolution Services (ERS) by email.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) Medicaid waiver services end the day before enrollment in the STAR+PLUS HCBS program.

 

3320 Coordination with Medicaid for the Elderly and People with Disabilities

Revision 18-2; Effective September 3, 2018

 

 

 

3321 General Eligibility Issues

Revision 19-1; Effective June 3, 2019

 

At the initial contact, Program Support Unit (PSU) staff must inform the medical assistance only (MAO) applicant or member and/or authorized representative (AR) that Medicaid for the Elderly and People with Disabilities (MEPD) specialists will complete a financial eligibility (Medicaid) determination. PSU staff should encourage the applicant or member and/or AR to cooperate with the MEPD specialist and to provide all verifications necessary in a timely manner.

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 MEPD specialists of the request for STAR+PLUS Home and Community Based Services (HCBS).

 

3321.1 Disability Determinations

Revision 19-1; Effective June 3, 2019

 

The following information is provided for informational purposes only regarding the disability determination process. Program Support Unit (PSU) staff have absolutely no role in this process.

If a STAR+PLUS Home and Community Based Services (HCBS) program applicant's or member's application for Supplemental Security Income (SSI) disability has been pending for over 90 days, the Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination. PSU staff will not be notified of the individual's Medicaid for the Elderly and People with Disabilities (MEPD) eligibility status until disability is determined. In order for DDU staff to make a disability determination, the MEPD specialist must obtain the following:

  • 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.

 

3322 Actions Pending Past the Medicaid for the Elderly and People with Disabilities Due Date

Revision 19-1; Effective June 3, 2019

 

Because Program Support Unit (PSU) staff depend on Medicaid for the Elderly and People with Disabilities (MEPD) staff to determine eligibility for medical assistance only (MAO) applicants, there are times when PSU staff must check with MEPD staff regarding the status of an application or program change.

Before contacting the MEPD specialist, PSU staff must ensure the MEPD time frame has expired. MEPD specialists have 45 days to complete applications for individuals over age 65. For individuals under age 65 whose disability has not yet been determined by the Social Security Administration (SSA), MEPD specialists have 90 days.

 

3330 STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services Program

Revision 21-2; Effective August 1, 2021

 

Medicaid members enrolled in STAR+PLUS qualify for Medicaid eligibility through various program types. Some members who request the STAR+PLUS Home and Community Based Services (HCBS) program may be Medicaid eligible through one of the following Medicaid program types:

  • Pickle (Type Program (TP)-03);
  • Disabled Adult Child (TP-18);
  • Disabled Widow(er) (TP-21);
  • Early Aged Widow(er) (TP-22);
  • Medicaid Buy-in (TP-87); or
  • Medicaid for Breast and Cervical Cancer (TA-67).

Although these Medicaid programs represent full Medicaid eligibility, they do not consider transfer of assets and substantial home equity reviews required to establish financial eligibility for the STAR+PLUS HCBS program. Therefore, these Medicaid types are not eligible for an upgrade and enrollment in the STAR+PLUS HCBS program until Medicaid for the Elderly and People with Disabilities (MEPD) specialists test for the additional criteria.

Managed care organizations (MCOs) must notify Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within three business days of an upgrade request for a member who has one of these Medicaid program types. PSU staff must contact the member within three business days of the uploading date of Form H2067-MC to advise the member Form H1200, Application for Assistance - Your Texas Benefits, must be completed and returned to PSU staff.

Once the member returns Form H1200, PSU staff send the signed and completed application form within two business days of receipt to the MEPD specialist, along with Form H1746-A, MEPD Referral Cover Sheet, identifying the action to be taken.

The MCO service coordinator must, within 45 days of a STAR+PLUS member's request for the STAR+PLUS HCBS program:

  • complete an assessment in order to prepare the individual service plan (ISP);
  • complete the Medical Necessity and Level of Care (MN/LOC) Assessment and submit it to Texas Medicaid & Healthcare Partnership (TMHP) to request medical necessity (MN);
  • upload Form H1700-1, Individual Service Plan, in the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal; and
  • upload Form H1700-3, Individual Service Plan – Signature Page, to TxMedCentral in the MCO's XXXISP folder, using the appropriate naming convention.

Within five business days of receipt of Form H1700-1 and Form H1700-3 from the MCO, PSU staff review the form to determine if the member meets eligibility criteria for the STAR+PLUS HCBS program.

If MN for a pending upgrade is denied, the MCO must inform PSU staff within three business days by uploading Form H2067-MC to TxMedCentral. When this occurs, PSU staff must send Form 1746-A to the MEPD specialist notifying the denial within three business days after receiving it from the MCO.

PSU staff must apply STAR+PLUS Program Support Unit Operational Procedures Handbook policy regarding upgrades to determine if the member meets the eligibility criteria for the STAR+PLUS HCBS program. This will include not only review of the functional criteria evaluated by the MCO, but also a determination that the member's Medicaid type is eligible for the STAR+PLUS HCBS program. For SSI-denied Medicaid program types referenced in this section, the Medicaid program type verification includes the MEPD certification that the additional required financial criteria have been met.

If not eligible, PSU staff:

  • follow actions in Section 3632, Program Support Unit (PSU)-Initiated Denials/Terminations, to deny the request;
  • send Form H2065-D, Notification of Managed Care Program Services, within three business days to the member; and
  • upload Form H2065-D to TxMedCentral to the MCO's SPWXXX folder.

If the member is eligible, PSU staff will process the member upgrade by:

  • completing Form H2065-D and send it to the member and (if applicable) the MEPD specialist;
  • uploading Form H2065-D in TxMedCentral to the MCO's SPWXXX folder; and
  • confirming Service Authorization System (SAS) entries to authorize eligibility for the STAR+PLUS HCBS program.

 

3400 Transferring Into STAR+PLUS

Revision 19-1; Effective June 3, 2019

 

Mandatory STAR+PLUS program members may continue to receive their current non-Medicaid services from the Texas Health and Human Services Commission (HHSC) until the managed care organization (MCO) is able to authorize Medicaid services. For example, a member would be able to continue to receive Family Care until the MCO authorizes personal attendant services (PAS). STAR+PLUS members are also entitled to be placed on an interest list for non-Medicaid services following policy specified in the Community Care Services Eligibility (CCSE) Handbook, Section 2230, Interest List Procedures.

Any application for new long-term services and supports (LTSS) from HHSC requires the mandatory member to be sent to her or his MCO first. This must be coordinated through Program Support Unit (PSU) staff. Refer to Section 3125, STAR+PLUS Home and Community Based Services Program Members Requesting Non-Managed Care Services.

Some STAR+PLUS Home and Community Based Services (HCBS) program applicants or members transferring in and out of STAR+PLUS will have an individual service plan (ISP) that is over the cost limit and is approved for general revenue (GR) funds. For these applicants or members, the losing service area must inform the gaining service area of the GR status. The gaining service area must follow the GR process.

 

3410 Transfer Scenarios

Revision 18-2; Effective September 3, 2018

 

 

 

3411 STAR+PLUS Home and Community Based Services Program Member Transferring to Another Service Area with Prior Knowledge

Revision 21-2; Effective August 1, 2021

 

When Program Support Unit (PSU) staff are notified of a transfer from one STAR+PLUS service area to another STAR+PLUS service area, within two business days, the losing PSU:

  • notify the gaining PSU staff a member is transferring to its service area and provides the member's:
    • name;
    • Social Security number;
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • send Form H1700-1, Individual Service Plan, to the gaining PSU staff;
  • send Form H1700-3, Individual Service Plan – Signature Page, to the gaining PSU staff;
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist using Form H1746-A, MEPD Referral Cover Sheet, on medical assistance only (MAO) individuals;
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address; and
  • upload Form H2067-MC to the managed care organization (MCO) XXXSPW folder in TxMedCentral using the appropriate naming convention, and requests Form H1700-1 and all forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the medical necessity/level of care (MN/LOC);
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.

Once the gaining PSU receives Form H1700-1 and H1700-3, PSU staff follow the usual intake procedures. The process is abbreviated since the member already has a:

  • medical necessity;
  • Resource Utilization Group; and
  • financial eligibility determination by MEPD, if applicable.

The gaining PSU coordinates all appropriate activities between the losing PSU, MCOs, member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining area.

The gaining PSU maintains contact with the member until the move is complete. Within five business days after the move, PSU staff:

  • send an email to ERS notifying ERS the member has moved;
  • manually close all Service Authorization System Online (SASO) records for the losing MCO effective the end of the month the member moves;
  • update SASO with the gaining MCO's information;
  • send Form H2065-D, Notification of Managed Care Program Services, to the member and include the begin and end dates of the individual service plan (ISP) in the Comments section; and
  • upload a copy of Form H2065-D to the appropriate MCO's XXXSPW folder in TxMedCentral, using the appropriate naming convention.

Within three business days of notification of the move, ERS disenrolls the member effective the end of the month in which the member moved and re-enrolls the member to the gaining MCO.

Refer to Appendix XXXI, STAR+PLUS Members Transitions from a Nursing Facility in one Service Area to the Community in Another Service Area, for additional information.

 

3412 STAR+PLUS Home and Community Based Services Program Member Transferring to Another Service Delivery Area Without Prior Knowledge

Revision 21-2; Effective August 1, 2021

 

When Program Support Unit (PSU) staff are notified a transfer from one STAR+PLUS service area to another STAR+PLUS area has already occurred, within one business day the losing PSU staff:

  • notify the gaining PSU staff a member has transferred to its service area and provides the member's:
    • name;
    • Social Security number;
    • Medicaid identification (ID) number;
    • current and future contact information; and
    • date of the move or anticipated move;
  • upload Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) XXXSPW folder in TxMedCentral, using the appropriate naming convention, and requests Form H1700-1, Individual Service Plan, and all the forms listed below from the losing MCO:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page;
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
    • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
    • the medical necessity and level of care (MN/LOC);
    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide; and
    • Form H2060-A, Addendum to Form H2060; and
    • Form H2060-B, Needs Assessment Addendum, as applicable.
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist using Form H1746-A, MEPD Referral Cover Sheet, for medical assistance only (MAO) individuals; and
  • remind Supplemental Security Income (SSI) members to contact the Social Security Administration (SSA) to change the address.

Within two business days of notification from the losing PSU staff, the gaining PSU staff:

  • contact the member to select an MCO from the gaining service area;
  • send the packet containing the MCO comparison chart; and
  • upload Form H2067-MC to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention, requesting the MCO to inform the gaining health plan of the move.

Upon receipt of Form H2067-MC, the gaining MCO must contact the member within one business day and begin services within two business days.

Once the gaining PSU staff receives Form H1700-1 and H1700-3, PSU staff follow the usual intake procedures. The process is abbreviated since the member already has a:

  • MN/LOC;
  • Resource Utilization Group (RUG); and
  • financial eligibility determination by the MEPD specialist, if applicable.

The gaining PSU staff coordinates all appropriate activities between the losing PSU, MCOs, the member, Enrollment Resolution Services (ERS) and other key parties to help ensure a successful transition. For PSU staff, this includes tracking each step of the process through the start of the new STAR+PLUS Home and Community Based Services (HCBS) program in the gaining area.

Within two business days after completing the steps above, the gaining PSU:

  • send an email to ERS notifying ERS the member has moved;
  • manually close all service authorization records effective the end of the month the member moves;
  • manually update the Service Authorization System Online (SASO) with the gaining MCO's information effective the first of the following month in which the move occurred;
  • send Form H2065-D, Notification of Managed Care Program Services, to the member (with the begin and end date of the ISP in the Comments section); and
  • upload a copy of Form H2065-D to the appropriate XXXSPW folder in TxMedCentral, using the appropriate naming convention.

Within two business days of notification of the move, ERS considers coordination of claims to limit provider impact.

Refer to Appendix XXXI, STAR+PLUS Members Transitioning from an NF in One Service Area to the Community in Another Service Area, for additional information.

 

3413 STAR+PLUS Home and Community Based Services Program Member Transferring from One MCO to Another Within the Same Service Area

Revision 20-1; Effective March 16, 2020

 

Once the initial enrollment period of one full month has passed, a member is eligible to change managed care organization (MCO) plans. A member may request a transfer to another MCO in the service area through the state-contracted enrollment broker at any time for any reason. Texas Health and Human Services Commission (HHSC) will make only one plan change per month. When a member wants to change from one MCO to another MCO in the same service area, the member or authorized representative (AR) must contact the enrollment broker via phone call to 1-800-964-2777.

If the member calls to change MCO on or before the monthly HHSC MCO enrollment cut-off date, the change will take place on the first day of the next month following the change request. If the member calls after the monthly HHSC MCO enrollment cut-off date, the change will take place the first day of the second month following the change request. The HHSC MCO enrollment cut-off date is not always on the same day of every month, but it is typically mid-month.

Examples:

  • If the member calls on April 9, the change will likely take place on May 1.
  • If the member calls on April 20, the change will likely take place on June 1.

HHSC Program Enrollment & Support prepares and sends a Monthly Plan Changes report to Program Support Unit (PSU) staff. The MCO can find the member-specific report located in the Monthly Enrollment (P34) File in TxMedCentral. The report gives a list of STAR+PLUS Home and Community Based Services (HCBS) program members who have changed MCOs from the previous month.

Within five business days of receiving the list and determining any new members, the gaining MCO must request from the losing MCO all applicable forms and documentation related to the new member, including all H1700 forms; all H2060 forms; any 1500 forms; the Medical Necessity and Level of Care (MN/LOC) assessment; Form H6516, Community First Choice Assessment; and any prior authorizations, as well as any one-time/lifetime limits that have been met. Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. If the gaining MCO experiences issues obtaining this information, the MCO must notify Managed Care Compliance and Operations (MCCO) staff.

The gaining MCO is responsible for service delivery from the first day of enrollment. Within 14 days of notification of the new member, the gaining MCO must contact the member to discuss services needed by the member. Within 30 days of notification of the new member, the gaining MCO must conduct a home visit to assess the member's needs. The gaining MCO must provide services and honor authorizations included in the prior individual service plan (ISP) until the new assessment is completed and the gaining MCO is able to complete a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, update the ISP and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with his or her existing provider(s) and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s needs.

 

3420 Individuals Transitioning to Services for Adults

Revision 19-1; Effective June 3, 2019

 

STAR Kids and STAR Health eligibility will terminate the last day of the month in which the member's 21st birthday occurs and the member must receive services through programs serving adults. The following services end at the end of the month following the member’s 21st birthday.

  • Medically Dependent Children Program (MDCP) operated by STAR Kids or STAR Health managed care organizations (MCOs); and
  • The Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services.

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.

Members who receive MDCP and/or PDN/PPECC may apply for services through STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program to continue to receive community services and avoid institutionalization beginning the 1st of the month following their 21st birthday.

 

3421 Procedures for Children Transitioning from STAR Kids/STAR Health Receiving Medically Dependent Children Program or Texas Health Steps Comprehensive Care Program/Private Duty Nursing or Prescribed Pediatric Extended Care Centers

Revision 18-2; Effective September 3, 2018

 

Members may receive a combination of the following services:

  • Medically Dependent Children Program (MDCP);
  • Private Duty Nursing (PDN); or
  • Prescribed Pediatric Extended Care Center (PPECC) services.

 

3421.1 Twelve Months Prior to the Member's 21st Birthday

Revision 19-1; Effective June 3, 2019

 

Twelve months prior to the 21st birthday of a STAR Kids or STAR Health member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Unit provides a copy of the MDCP PDN Transition Report, which lists members enrolled in STAR Kids/STAR Health and receiving MDCP, CCP/PDN or PPECC services, who may transition to STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program in the next 18 months to the:

  • Program Support Unit (PUS) supervisor; and
  • UR Unit for Intellectual or Developmental Disabilities (IDD) Waiver/Community Services/Hospice.

The STAR Kids and STAR Health managed care organizations (MCOs) identify all members turning age 21 within the next 12 months and schedule a face-to-face visit with the member and the member's support person including her or his authorized representative (AR), if applicable, to initiate the transition process.

During the face-to-face visit with the member, her or his support person or AR, the MCO must present an overview of STAR+PLUS, including the STAR+PLUS HCBS program, and the changes that will take place when the member transitions to STAR+PLUS. Specific information that must be provided during the face-to-face visit can be found in the STAR Kids Handbook, Appendix VI, STAR Kids Transition Activities, or for STAR Health, in the Uniform Managed Care Manual.

The STAR Kids MCO:

  • monitors transition activities with the member or the support person, including her or his AR, every 90 days during the year before the member turns age 21; and
  • notifies UR via email indicating the member appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program. This notification must include the number of PDN hours currently authorized.

The STAR Health MCO notifies UR via email indicating the member appears to meet the criteria in Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program. The notification must include the number of PDN hours currently authorized.

The UR Transition/High Needs coordinator must:

  • monitor the MDCP PDN Transition Report and identify all STAR Health members turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); and
    • Texas Home Living (TxHmL).
  • coordinate with UR staff for the IDD waivers and PSU staff if it is determined the member has high needs and/or needs to be assessed for the STAR+PLUS HCBS program.

PSU staff:

  • monitor the MDCP PDN Transition Report and identifies all members receiving MDCP, PDN or PPECC services turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) Medicaid waivers:
    • CLASS;
    • DBMD;
    • HCS; or
    • TxHmL.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder earlier than five months prior to the member’s 21st birthday. 

The following chart outlines the responsibilities for monitoring the MDCP PDN Transition Report and contacting members transitioning from STAR Kids/STAR Health who receive MDCP waiver and/or PDN/PPECC 12 months prior to the member’s 21st birthday.

Twelve Month Transition Chart
Under Age 21 MDCP Under Age 21 Other Services Received Monitors MDCP PDN Transition Report 12-Month Contact

MDCP

PDN-CCP or PPECC-CP

PSU Staff

MCO

MDCP

None

PSU Staff

MCO

Not Applicable

PDN-CCP

PSU Staff

MCO

Not Applicable

PPECC-CCP

PSU Staff

MCO

 

3421.2 Nine Months Prior to the Member's 21st Birthday

Revision 19-1; Effective June 3, 2019

 

Nine months prior to the 21st birthday of a member receiving the Medically Dependent Children Program (MDCP), Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) service, the following process begins.

The STAR Kids and STAR Health managed care organization (MCO):

  • monitors transition activities with the member and the member’s available supports, including her or his authorized representative (AR), every 90 days during the year before the member turns age 21; and
  • notifies Program Support Unit (PSU) staff of any issues or concerns by using Form H2067-MC, Managed Care Programs Communication, and uploads to TxMedCentral.

PSU staff:

  • monitor the MDCP PDN Transition Report and identify all members transitioning from STAR Kids and receiving MDCP and/or PDN/PPECC turning age 21 in nine months and not enrolled in one of the following intellectual and developmental disability (IDD)1915(c) Medicaid waivers:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS); and
    • Texas Home Living (TxHmL);
  • send the STAR Kids member Form 2114, Nine-Month Transition Letter, along with a STAR+PLUS enrollment packet (including the STAR+PLUS MCO list and comparison chart). The letter will serve as an introduction to the process and advise the member, support person or AR. PSU staff will contact the member or member’s support person, or AR, within 30 days to discuss the transition process and review the enrollment packet; and
  • update the case in the Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) by:
    • documenting the date the Initial Transition letter was sent out;
    • uploading the Initial Transition letter to HEART;
    • documenting the due date for the telephonic contact 30 days from the date the STAR+PLUS Home and Community Based Services (HCBS) program enrollment packet is mailed; and
    • uploading Form H2067-MC if the MCO documented any issues or concerns.

Note: PSU staff must not upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder earlier than five months prior to the member's 21st birthday.

 
Within 30 days of the enrollment packet mailing, PSU schedule and complete a telephonic contact with the member or the member’s available supports, including her or his authorized representative, to explain the following:

  • STAR Kids eligibility, MDCP or PDN/PPECC services will terminate on the last day of the month in which the member’s 21st birthday occurs.
  • The STAR+PLUS HCBS program is an option available to eligible members at age 21. PSU staff also presents an overview of the array of services available within the STAR+PLUS HCBS program.
  • The STAR+PLUS program enrollment packet sent to the member is reviewed. The packet contains a list of the STAR+PLUS MCOs in the service area and a comparison chart to assist the member in making a selection. The member will choose a STAR+PLUS MCO in her or his service area that will perform the assessment for services and oversee the delivery of services.
  • The importance of choosing an MCO six months before the 21st birthday in order to avoid having a gap in services.
  • The member can change MCOs any time after the first month of enrollment.
  • The STAR+PLUS HCBS program has a cost limit based on a medical assessment, the Medical Necessity and Level of Care (MN/LOC) Assessment. The assessment results in the cost limit for the individual service plan (ISP).
  • To be eligible for the STAR+PLUS HCBS program, an ISP must be developed within the cost limit that will meet the member's needs and ensure health and safety.
  • If an ISP cannot be developed within the cost limit that ensures member’s health and safety in the community, the STAR+PLUS HCBS program will be denied.
  • The ISP considers all resources available to meet the member's needs, including community supports, other programs, and what the member's informal support system can provide to meet the member's needs.
  • The STAR+PLUS HCBS program assessment process will begin six months before the member's 21st birthday. PSU staff will contact the member to begin the application process and find out which MCO has been selected. If an MCO has not been selected, then 30 days is allowed for a selection. After 30 days, an MCO is selected for the member.
  • After the MCO is selected, the MCO service coordinator will contact the member to begin the assessment for services and assist the member, the member’s support person, or his/her authorized representative in identifying and developing additional resources and community supports to help meet the member's needs.
  • The MCO service coordinator will assist the member in determining the services needed within this service array to meet his needs and ensure health and safety. Example: If other needs are met, but the member primarily requires nursing, then an ISP can be developed with the maximum number of nursing hours within the cost limit while the member's other needs are met through other resources.
  • Reassure the member, support person or AR that every effort will be made to help him or her make a successful transition to the STAR+PLUS HCBS program.
  • The member may potentially receive an enrollment packet from the Texas Health and Human Services Commission (HHSC) enrollment broker and the importance of selecting the same MCO.

 

3421.3 Five Months Prior to the Member's 21st Birthday

Revision 19-1; Effective June 3, 2019

 

Five months prior to the 21st birthday of a member receiving Medically Dependent Children Program (MDCP) or Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) services, and within 30 days of the previous contact, Program Support Unit (PSU) staff contact the member or authorized representative (AR) by telephone.

If the member or AR receiving MDCP and/or CCP/PDN or PPECC has made a managed care organization (MCO) and primary care provider (PCP) choice:

  • the member or AR receiving MDCP and/or CCP/PDN or PPECC informs PSU staff of the MCO choice; and
  • PSU staff inform the:
    • member that he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity;
    • MCO of the member's choice by uploading Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the XXXSPW folder, using the appropriate naming convention; and
    • MCO of a member receiving 50 or more PDN hours by noting the PDN hours in the comments field of Form H3676, Section A.

If the member or AR has not made an MCO and PCP choice:

  • PSU staff inform the member or AR that if an MCO is not selected within seven days from the PSU contact, one will be assigned; and
  • if the selection is not made within seven days from the PSU contact, PSU staff:
    • select an MCO for the member;
    • inform the member that:
      • the state has selected an MCO; and
      • he or she must remain with this MCO through the first month of STAR+PLUS enrollment to ensure a smooth transition and service continuity; and
    • inform the MCO of the choice by uploading Form H3676 to TxMedCentral in the XXXSPW folder, using the appropriate naming convention.

Note: Within 14 days of the PSU Form H3676 uploading date, the MCO must schedule the initial home visit with the MDCP or CCP/PDN member or AR.

 

3421.4 Within 45 Days of Receiving Notification of a Form H3676 Referral

Revision 21-2; Effective August 1, 2021

 

Within 45 days of receiving email notification of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, the managed care organization (MCO):

  • completes either Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment;
  • completes the Medical Necessity and Level of Care (MN/LOC) Assessment, using Service Group 19, and submits the form to the Long Term Care (LTC) Online Portal (Note: The initial MN/LOC may not be submitted earlier than 150 days prior to the first day of the month following the 21st birthday of the member);
  • makes a referral to a Local Intellectual and Developmental Disability Authority (LIDDA), for members who may have an intellectual or developmental disability (IDD), so the LIDDA can complete the necessary assessments used to determine whether the member meets the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level of care (LOC) necessary to qualify for Community First Choice (CFC);
  • completes Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page, according to STAR+PLUS HCBS program eligibility referenced in Section 3421.6 that follows;
  • uploads Form H1700-1 and Form H1700-3 to TxMedCentral in the MCO's XXXISP folder, using the appropriate naming convention. An approved MN/LOC must be received before uploading Form H1700-1, if the member has a need for the STAR+PLUS HCBS program;
  • completes Section B of Form H3676; and
  • uploads Form H3676 to TxMedCentral in the MCO XXXSPW folder, using the appropriate naming convention.

 

3421.5 Confirm STAR+PLUS Home and Community Based Services Program Eligibility

Revision 19-1; Effective June 3, 2019

 

Program Support Unit (PSU) staff confirm eligibility within five business days of receipt of all required eligibility documentation from the managed care organization (MCO) and Texas Medicaid & Healthcare Partnership (TMHP), based on:

  • an approved medical necessity and level of care (MN/LOC);

    Note: A valid MN does not exceed 150 days from the date of TMHP approval. If MN exceeds 150 days from date of TMHP approval, PSU staff must complete Form H2067-MC, Managed Care Programs Communication, advising the MCO, and requesting the MCO process a significant change in condition to the MN. PSU staff must upload Form H2067-MC to TxMedCentral in the MCO’s SPW folder.

  • at least one STAR+PLUS Home and Community Based Services (HCBS) program service is listed on the individual service plan (ISP); and
  • an ISP cost within 202 percent of the Resource Utilization Group (RUG) cost limit. Note: If the ISP exceeds 202 percent of the RUG, refer to Section 3421.6, ISP Cost Exceeds 202 Percent of the RUG Cost Limit.

PSU staff must request STAR+PLUS HCBS program enrollment from Enrollment Resolution Services (ERS) no later than 60 days prior to the individual's 21st birthdate so the Texas Health and Human Services Commission (HHSC) enrollment broker does not send a STAR+PLUS HCBS program enrollment packet to the individual.

If STAR+PLUS HCBS program eligibility is approved, within two business days, PSU staff:

  • establish the start-of-care date, which is the first of the month following the member’s 21st birthday;
    For example, the 21st birthday of the member receiving the Medically Dependent Children Program (MDCP) or Comprehensive Care Program (CCP)/Private Duty Nursing (PDN), or Prescribed Pediatric Extended Care Centers (PPECC) is March 3, 20XX:
    • STAR+PLUS HCBS program registration is effective April 1, 20XX;
    • ISP is entered for the STAR+PLUS HCBS program ISP period; and
    • STAR+PLUS HCBS program registration is April 1, 20XX, to March 31, 20XX;
  • complete Form H2065-D, Notification of Managed Care Program Services, and
    • send the original to the member;
    • upload Form H2065-D to the HHS Enterprise Administrative Report and Tracking System (HEART); and
    • upload From H2065-D to TxMedCentral in the MCO's XXXSPW folder, using the appropriate naming convention.

Within five business days of receipt of Form H2065-D from PSU staff, ERS:

  • forces enrollment of the member into STAR+PLUS in the Texas Integrated Eligibility Redesign System (TIERS); and
  • establishes STAR+PLUS enrollment effective the first day of the month following the 21st birthday of the member receiving MDCP or CCP/PDN or PPECC. Note: If the member's birthday is the first day of the month, enrollment is effective the same day and month following the 21st birthday of the member receiving MDCP or CCP/PDN or PPECC.

 

3421.6 Individual Service Plan Cost Exceeds 202 Percent of the Resource Utilization Group Cost Limit

Revision 21-2; Effective August 1, 2021

 

If the initial or annual reassessment individual service plan (ISP) cost exceeds 202 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits the documents below, after being reviewed and approved by the MCO medical director, to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

 

  • Medical Necessity and Level of Care (MN/LOC) Assessment;
  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-3, Individual Service Plan – Signature Page;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, as appropriate;
  • Form H2060-A, Addendum to Form H2060, if applicable;
  • Form H2060-B, Needs Assessment Addendum;
  • Form 485, CMS Home Health Certification and Plan of Care, or Plan of Care with the same components contained in Form 485;
  • Form 1024, Individual Status Summary;
  • Primary Care/Specialty Physician office visit notes documenting the current medical condition of the individual (office visit notes must be dated within the last 12 months - do not submit office visit notes from a nurse practitioner or physician assistant); and
  • Two weeks of nursing notes, including Medication Administration Records, seizure, vent and suction logs, as applicable.

UR staff will conduct a desk review once all the documents noted above are received and may request a clinical review of the case by an HHSC physician to consider the use of state of Texas General Revenue (GR) funds to cover costs exceeding the 202 percent cost limit. If HHSC is unable to make a determination based on the documentation submitted, additional information will be requested from the MCO. MCOs must submit documentation supporting a GR request no later than 45 days:

  • From the MCO’s receipt of Form H3676, Managed Care Pre-enrollment Assessment Authorization;
  • From identified need or request for STAR+PLUS Home and Community Based Services (HCBS) for an individual who is enrolled in STAR+PLUS and has experienced a change in condition;
  • Prior to the ISP effective date for individuals enrolled in STAR+PLUS HCBS and who have experienced a change in condition at the time of their reassessment; or
  • Prior to the ISP effective date for individuals enrolled in STAR+PLUS HCBS who are already approved for GR at the time of their reassessment.

Note: HHSC UR staff will coordinate a conversation with the member, their authorized representative (if applicable), and the MCO to discuss the process for HHSC to request the use of GR for services above the cost limit.

 

3422 Intrapulmonary Percussive Ventilator

 

Revision 19-1; Effective June 3, 2019

 

Members who were approved for and are using an intrapulmonary percussive ventilator (IPV) are permitted to continue using the IPV if it is deemed to have a beneficial impact on the health of the member. The member must not be subjected to abrupt removal of the equipment. The member continues to receive ongoing IPV treatment until a final decision is made by the STAR+PLUS managed care organization (MCO), on a case-by-case basis, including thorough review and documentation by the MCO and explicit approval by Texas Health and Human Services Commission (HHSC) Office of the Medical Director.

 

3500 Money Follows the Person

Revision 18-2; Effective September 3, 2018

 

See Section 3311.1, Interest List Procedures, for information regarding use of the Community Services Interest List as a tracking system for 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 19-1; Effective June 3, 2019

 

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 Minimum Data Set (MDS) Assessment, medical necessity and level of care (MN/LOC), and Program Support Units (PSUs) can accept an NF’s MDS Assessment for MFP applicants as long as they are approved and have not yet expired. The NF’s MDS Assessment may not be used for upgrades. For more information about upgrades, see Section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services Program.

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 Services, for an approval are denied using Denial Code 39 (Other).

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.

See 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 Initiative.

 

3511 Money Follows the Person Procedure

Revision 18-2; Effective September 3, 2018

 

A referral is made through the Texas Health and Human Services Commission (HHSC) Access and Eligibility when a nursing facility (NF) resident wishes to receive services in the community through the STAR+PLUS Home and Community Based Services (HCBS) program. 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 Money Follows the Person Applications Pending Due to Delay in Nursing Facility Discharge

Revision 19-1; Effective June 3, 2019

 

In keeping with the Promoting Independence Initiative, the Program Support Unit (PSU) and managed care organizations (MCOs) 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-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 months from the date services were requested. Allow the referral to remain open until the member 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 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–month period, PSU staff should keep the request for services open. See Section 3513 below for information about applications pending more than four months.

 

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

Revision 19-1; Effective June 3, 2019

 

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

Applicants who have not made any living arrangements to return to the community, cannot decide when to return to the community, or have no viable plan or support system in the community should be denied. PSU staff deny the request for services by sending Form H2065-D, Notification of Managed Care Program Services, to the applicant within two business days after the end of the four-month pending period. PSU staff will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's SPW folder.

If an assisted living (AL) applicant meets eligibility criteria but is on an interest list for a contracted STAR+PLUS HCBS program AL facility (ALF), PSU staff verify through the MCO that the applicant is on the list and may leave the service request pending until the slot opens.

 

3514 STAR+PLUS Members Residing in a Facility

Revision 19-1; Effective June 3, 2019

 

When a managed care organization (MCO) receives a request from, or becomes aware of, a STAR+PLUS member who is requesting to transition to the community, the MCO service coordinator must contact the applicant or member within five business days and must meet with the member within 14 business days to explain the process of transitioning to the community.

  • Within three business days after meeting with the member, the MCO service coordinator must make a referral for relocation assistance by completing Form 1579, Referral for Relocation Service, if applicable.
  • Inform Program Support Unit (PSU) staff of the request to transition to the community by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral using the appropriate naming convention for Money Follows the Person (MFP).

Within two business days after the MCO has uploaded Form H2067-MC, PSU staff must:

  • inform the MCO if the member is on a 1915(c) Medicaid interest list, in a 1915(c) Medicaid waiver notated as open enrollment or services temporarily suspended, or neither, by uploading Form H2067-MC to TxMedCentral.

Within 45 days after becoming aware of a member requesting to transition to the community, the MCO service coordinator must have completed the assessment for the applicant or member for the appropriate services and community settings. The MCO completes the following activities:

  • The MCO completes the Medical Necessity and Level of Care (MN/LOC) assessment if there is no valid Minimum Data Set (MDS) assessment or has the option to complete its own MN/LOC assessment in lieu of using the nursing facility's (NF's) MDS.
    • The MCO should ask the NF for a courtesy copy of the MDS Assessment completed by the NF. If the NF refuses, it is not mandatory for the MCO to have a copy.
    • A denied MN/LOC decision resulting from the assessment the MCO submits is not used to deny a STAR+PLUS Home and Community Based Services (HCBS) program applicant who has a valid NF MDS. The NF MDS and Resource Utilization Group (RUG) are used for STAR+PLUS HCBS program eligibility determinations.
    • An 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 end date and must have an active MN period covering the entire ISP period. The MN/LOC end date must be adjusted to match the ISP end date, if necessary.
  • If a Supplemental Security Income (SSI) or SSI-related member will only be receiving state plan Long-term Services and Supports (e.g., personal assistance services (PAS) or Day Activity and Health Services (DAHS)), the MCO must inform the PSU staff by uploading Form H2067-MC to TxMedCentral
  • If the member meets functional criteria for the STAR+PLUS HCBS program, the MCO follows policy in Section 3514.1, Transition to Community with STAR+PLUS Home and Community Based Services Program.

 

3514.1 Transition to Community with STAR+PLUS Home and Community Based Services Program

Revision 21-2; Effective August 1, 2021

 

During the initial 45-day time frame for the assessment, if the member is temporarily suspended from a Texas Health and Human Services Commission (HHSC) 1915(c) Medicaid waiver, the managed care organization (MCO) service coordinator explains the STAR+PLUS Home and Community Based Services (HCBS) program to the member so he or she can choose between the STAR+PLUS HCBS program or remain in her or his previous HHSC 1915(c) Medicaid waiver.

  • If the member chooses the STAR+PLUS HCBS program, the MCO service coordinator:
    • reviews the current Form H1700-1, Individual Service Plan, or develops a new individual service plan (ISP) if one previously did not exist or if the ISP has expired;
    • coordinates Transition Assistance Services (TAS) as part of the STAR+PLUS HCBS program, if needed;
    • notifies Program Support Unit (PSU) staff the member has selected the STAR+PLUS HCBS program; and
    • notifies PSU staff of the selection by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral using the Money Follows the Person (MFP) naming convention.
  • If the member chooses to remain with the HHSC 1915(c) Medicaid waiver, the MCO service coordinator notifies PSU staff of the selection by uploading Form H2067-MC to TxMedCentral using the MFP naming convention.

Within two business days of receipt of Form H2067-MC from the MCO notifying them of the member’s selection, PSU staff completes the following activities:

  • If the member chooses the STAR+PLUS HCBS program, PSU staff:
    • upload Form H2067-MC to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
    • add the member to the STAR+PLUS interest list, if applicable; and
    • immediately release the member from the interest list.
  • If the member chooses to return to the HHSC 1915(c) Medicaid waiver for services, PSU staff:
    • upload Form H2067-MC to HEART; and
    • close the case in HEART.

For Medicare/Medicaid dually eligible individuals who became members during the nursing facility (NF) stay but have chosen to return to the HHSC 1915(c) Medicaid waiver, PSU staff notify Enrollment Resolution Services (ERS) to request disenrollment at the time of discharge.

When the member chooses the STAR+PLUS HCBS program, the MCO coordinates with HHSC relocation contractors and Local Intellectual and Developmental Disability Authority (LIDDA) service coordinators, as needed, to ensure everything required for community living is in place at the time of discharge from the NF. Supplemental Transition Support (STS) services must be specialist between the relocation contractor and the MCO service coordinator when the relocation specialist determines the member may benefit from STS services. See Appendix XXX, Relocation Function, for responsibilities of relocation specialists and MCOs. The MCO is not responsible for obtaining independent housing for the member, but is responsible for identifying adult foster care (AFC) or assisted living (AL) alternatives available in the network.

For all members transitioning into the STAR+PLUS HCBS program, within 45 days, the MCO uploads the following information to TxMedCentral:

  • Form H1700-1 and Form H1700-3, if the ISP has expired or one did not previously exist; and
  • Form H2067-MC notifying PSU staff if the NF discharge date is known.

PSU staff send an email to the Managed Care Compliance & Operations if the MCO does not upload the above information within 45 days after the member's request to return to the community. PSU staff continue to monitor for receipt of the above information when required. Within five business days after receipt of all required documentation, PSU staff:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid eligibility for STAR+PLUS;
    • an approved medical necessity; and
    • an ISP with:
      • at least one STAR+PLUS HCBS program service per year; and
      • a cost within the individual's cost limit;
  • send an initial Form H2065-D, Notification of Managed Care Program Services, to the member as notification he or she has met the eligibility qualifications to participate in the STAR+PLUS HCBS program; and
  • upload a copy of Form H2065-D to TxMedCentral within two business days to inform the MCO PSU staff sent the notice of initial eligibility determination to the member.

Once STAR+PLUS HCBS program eligibility is approved, the MCO, relocation specialist, NF, NF resident and PSU staff collaborate to identify a proposed discharge date. The MCO is the responsible party for notifying PSU staff of the discharge date by uploading Form H2067-MC to TxMedCentral. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by uploading Form H2067-MC to TxMedCentral to determine if the date is acceptable. The MCO must respond with the correct scheduled discharge date by uploading Form H2067-MC to TxMedCentral within two business days of PSU staff's Form H2067-MC uploading date.

Within two business days of the individual's discharge from the NF, the MCO uploads Form H2067-MC to TxMedCentral to communicate the discharge to PSU staff. Within one business day, PSU staff complete a second Form H2065-D containing the service effective date and:

  • mail the original to the member;
  • upload a copy to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • for medical assistance only (MAO) members, fax or email a copy of Form H2065-D, as well as Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to facilitate the Medicaid program transfer; and
  • email Form H2065-D to the Enrollment Resolution Services (ERS) Unit mailbox requesting enrollment from STAR+PLUS, if applicable.

Within one business day of mailing the final Form H2065-D to the member, PSU staff create Service Authorization System Online (SASO) entries documented in Section 9400, Money Follows the Person (MFP) Authorization for a STAR+PLUS HCBS Program Applicant, with the exception of creating a one day STAR+PLUS service authorization for the first day of the month in which an MFP individual is discharged from an NF. It is not necessary to complete a one-day service authorization record for members who discharge mid-month and begin receiving the STAR+PLUS HCBS program.

If the NF records in SASO do not reflect the NF end date within three business days of the individual's discharge date, PSU staff will contact the HHSC Long Term Care (LTC) Provider Claims Services department to request closure of the NF service authorization in SASO. The hotline for HHSC Provider Claims is 512-438-2200. Select Option 1 when prompted to do so.

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D and:

  • mail the original to the member; and
  • upload it to TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention.

If a Medicaid eligibility NF MAO member chooses to leave the NF and return to the community before being determined eligible for the STAR+PLUS HCBS program, PSU staff perform the following steps additional to those referenced above:

  • fax or email a copy of Form H2065-D, along with Form H1746-A, to the MEPD specialist;
  • email a copy to ERS requesting disenrollment from STAR+PLUS; and
  • upload Form H2065-D to HEART.

 

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

Revision 21-2; Effective August 1, 2021

 

For requests to transition to the community for a non-STAR+PLUS member, the Texas Health and Human Services Commission (HHSC) Access and Eligibility staff make a referral to Program Support Unit (PSU) staff. Within two business days of the referral from HHSC, PSU staff:

  • determine whether the individual has either an open enrollment or services have been temporarily suspended in an HHSC 1915(c) Medicaid waiver according to the following:
    • For either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waivers, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify if the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable.
    • For the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to see if the service authorization record for these waivers has an end date and a termination code. If the service authorization has an end date and no termination code, this indicates the waiver has been temporarily suspended.
  • coordinate with the Local Intellectual and Developmental Disability Authority (LIDDA) to schedule a conference call with the individual to explain the benefits of the STAR+PLUS Home and Community Based Services (HCBS) program and the HHSC 1915(c) Medicaid waivers;
  • open a case in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART); and
  • document the member's STAR+PLUS HCBS program choice in HEART.

Within two business days of receipt of the notification of the nursing facility (NF) resident's STAR+PLUS HCBS program selection, PSU staff determine the individual's Medicaid status to evaluate for proper coordination with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

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

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify if either Form H1200, Application for Assistance – Your Texas Benefits, has already been submitted for the NF stay, or the individual already has full Medicaid eligibility for a type program applicable to the STAR+PLUS HCBS program.
  • Contact or attempt to contact the NF resident or authorized representative (AR) party by phone to explain the Medicaid application process, when applicable, the selection of a managed care organization (MCO) and the importance of promptly returning the forms that PSU staff mail to the individual.
  • Inform the NF resident during the telephone contact that he or she may change the MCO in which he or she is enrolled at any time after one full month of the STAR+PLUS HCBS program provision.
  • Send Form H1200, when applicable, and the appropriate STAR+PLUS MCO enrollment packet to the NF resident, responsible party or AR.
  • Check the Community Services Interest List (CSIL) to see if the resident is already on the STAR+PLUS HCBS program interest list. If not, add and immediately release the individual from the STAR+PLUS HCBS program interest list.
  • Refer the individual for relocation assistance by completing Form 1579, Referral for Relocation Services.
  • Notify HHSC the individual is applying for the STAR+PLUS HCBS program.

PSU staff are responsible for completing the following activities 14 days following the STAR+PLUS HCBS program selection. PSU staff must document in HEART all attempted contacts with the NF resident and any encountered delays. PSU staff:

  • contact the NF resident if PSU staff have not received Form H1200; and
  • discuss with the NF resident the importance of choosing an MCO if the individual did not select one during the initial contact, explaining the MCO conducts the assessment and develop the initial individual service plan (ISP) to facilitate an eligibility determination for the STAR+PLUS HCBS program.

If, during the 14-day follow-up contact, the NF resident states that he or she, the AR or the NF has already submitted a completed Form H1200, PSU staff check the Texas Integrated Eligibility Redesign System (TIERS) to verify Form H1200 has been submitted. If the NF resident communicates Form H1200 has not been submitted, or if TIERS does not have a record Form H1200 has been submitted, the PSU notifies the NF resident to immediately return Form H1200 to PSU staff because the application for SPW services will be denied for failure to return the Form H1200 within 45 days from the date the PSU sent the form to the NF resident. Upon receipt of the completed Form H1200, PSU staff make a referral to the MEPD specialist within two business days by completing Form H1746-A, MEPD Referral Cover Sheet, to include submission of the returned Medicaid application.

If Form H1200 is not received within 45 days from the date PSU staff sent Form H1200 to the NF resident, PSU staff deny the application for the STAR+PLUS HCBS program by:

  • documenting in HEART Form H1200 was not received within 45 days;
  • sending the NF resident Form H2065-D, Notification of Managed Care  Program Services; and
  • uploading Form H2065-D to TxMedCentral using the appropriate naming convention.

Within two business days from when the NF resident notifies PSU of the MCO selection orally or in writing, or from when the member is defaulted to an MCO, PSU staff must:

  • check SASO to determine if the applicant has a current medical necessity and level of care (MN/LOC);
  • complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating whether the applicant has a current MN by entering the Resource Utilization Group (RUG) and expiration date in Item 6;
  • upload Form H3676 to the MCO's XXXSPW folder on TxMedCentral using the appropriate naming convention;
  • upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, notating whether or not the applicant is on an HHSC 1915(c) Medicaid waiver interest list; and
  • ensure the appropriate items on Form H3676 are completed and faxed to the relocation specialist, if the NF resident requires assistance transitioning to the community because of lack of supports, lack of housing or other barriers.

The MCO initiates contact with the applicant to begin the assessment process within 14 days of receipt of Form H3676. Within 45 days from receipt of Form H3676, the MCO service coordinator assesses the applicant for the appropriate services and community settings. The MCO completes the following activities

  • The MCO completes the MN/LOC Assessment if there is no valid Minimum Data Set (MDS) or has the option to complete its own MN/LOC assessment in lieu of using the NF’s MDS. If there is no valid MDS, the MCO completes the MN/LOC for an MN determination.
    • The MCO should ask the NF for a courtesy copy of the MDS Assessment completed by the MDS. If the NF refuses, it is not mandatory for the MCO to have a copy.
    • A denied MN/LOC decision resulting from the assessment the MCO submits is not used to deny a STAR+PLUS HCBS program applicant who has a valid NF MDS. The NF MDS and RUG are used for STAR+PLUS HCBS program eligibility determinations.
    • An MN record must be located in SAS so the ISP registration does not suspend. The SASO MN record must match the ISP effective end date and must have an active MN period covering the entire ISP period. The MN/LOC end date must be adjusted to match the ISP end date, if necessary.
  • If the applicant requires services through the STAR+PLUS HCBS program, the MCO completes Section B of Form H3676 and develops the ISP using Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page.
  • If a referral for relocation services is not indicated in section A of Form H3676 and the applicant needs these services, the MCO updates Form H3676, Section B, and sends Form 1579 to the relocation specialist.
  • If the applicant is not eligible for the STAR+PLUS HCBS program, the MCO must inform PSU staff by uploading Form H2067-MC to TxMedCentral.

When the MCO has determined the applicant meets the functional eligibility requirements for the STAR+PLUS HCBS program, the MCO coordinates with the relocation specialists to ensure everything needed for community living is in place at the time of discharge from the NF. The MCO must coordinate Transition Assistance Services (TAS) when needed by the applicant as part of the STAR+PLUS HCBS program. The MCO is not responsible for obtaining independent housing for the NF resident, but is responsible for identifying adult foster care (AFC) or assisted living (AL) alternatives available in the network. When the applicant needs Supplemental Transition Support (STS) services, relocation specialists must coordinate these through the MCO service coordinator.

As needed, PSU staff collaborate with involved parties throughout the STAR+PLUS HCBS program eligibility determination process to assist with problem resolution and to document any delays. PSU staff track all actions and communications in HEART until all STAR+PLUS HCBS program enrollment activities are complete.

Within 45 days of receiving Form H3676 with Section A, the MCO uploads the following information to TxMedCentral:

  • Form H1700-1;
  • Form H1700-3;
  • Form H3676 with Section B completed; and
  • Form H2067-MC, notifying PSU staff of the NF proposed discharge date.

PSU staff send an email to Managed Care Compliance & Operations (MCCO) if the MCO does not upload the above information within 45 days after the NF resident's request to return to the community. PSU staff continue to monitor for receipt of the above-referenced forms. Within two business days of receipt of this information, if Medicaid is pending, PSU staff complete and send Form H1746-A, MEPD Referral Cover Sheet, to notify the MEPD specialist of the approved ISP and MN/LOC so the MEPD specialist can complete the Medicaid eligibility determination.

Upon completion of the evaluation for financial eligibility, the MEPD specialist notifies PSU staff of the determination by sending an email to the appropriate mailbox designated for the MEPD specialist to submit communications to PSU staff.

Within five business days after receipt of all MCO documentation required for STAR+PLUS HCBS program eligibility, as well as communication from the MEPD specialist of the applicant's Medicaid eligibility, PSU staff:

  • confirm STAR+PLUS HCBS program eligibility based upon:
    • Medicaid eligibility for STAR+PLUS;
    • an approved MN/LOC;
    • an ISP with:
      • at least one STAR+PLUS HCBS program;
      • a cost within the individual's cost limit; and
  • send the initial Form H2065-D to the member and upload a copy to TxMedCentral to inform the MCO PSU staff notified the individual of this determination.

The MCO collaborates with the relocation specialist, NF, NF resident and PSU staff to identify a proposed discharge date. Once the discharge date has been determined, the MCO must notify PSU staff of the discharge date within two business days by uploading Form H2067-MC to TxMedCentral. Should any other entity contact PSU staff with a discharge date, PSU staff must notify the MCO within two business days by uploading Form H2067-MC to TxMedCentral to determine if the date is acceptable. The MCO resolves this discrepancy and must confirm the scheduled discharge date by uploading Form H2067-MC to TxMedCentral within two business days of PSU’s Form H2067-MC uploading date.

Within two business days of the individual's discharge from the NF, the MCO uploads Form H2067-MC to TxMedCentral to communicate the discharge to PSU staff. Within one business day, PSU staff complete the final Form H2065-D containing the service effective date and:

  • mail the original to the individual;
  • upload it on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • fax or email a copy, as well as Form H1746-A, to the assigned MEPD specialist for generation of a pending task in TIERS; and
  • email Form H2065-D to the Enrollment Resolution Services (ERS) Unit mailbox requesting enrollment from STAR+PLUS, if applicable.

Within one business day of sending the final Form H2065-D, PSU staff:

  • verify that NF records in the SASO reflect the NF end date;
  • contact HHSC Long Term Care (LTC) Provider Claims at 512-438-2200 and select option 1 to request closure of the NF service authorization in SAS if the NF end date reflecting the discharge has not processed;
  • update the CSIL, ensuring accurate selection of the CSIL closure code(s); and
  • email Enrollment Resolution Services (ERS) requesting enrollment effective the first of the month in which the individual is discharged, as required by Section 3510, Money Follows the Person and Managed Care.

If STAR+PLUS HCBS program eligibility is denied, PSU staff complete Form H2065-D, and:

  • mail the original to the applicant;
  • upload Form H2065-D on TxMedCentral in the MCO's XXXSPW folder using the appropriate naming convention;
  • upload Form H2065-D to HEART;
  • close the case in HEART; and
  • close CSIL.

If the applicant chooses to leave the NF before being determined eligible for the STAR+PLUS HCBS program, PSU staff deny the STAR+PLUS HCBS program and fax Form H2065-D, along with Form H1746-A, to the MEPD specialist. Upon completion of all STAR+PLUS HCBS program actions, PSU staff close the case in HEART.

 

3520 Money Follows the Person Demonstration

Revision 20-1; Effective March 16, 2020

 

 

 

3521 Money Follows the Person Demonstration Introduction

Revision 20-1; Effective March 16, 2020

 

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 the manner in which services are delivered. Individuals participating in MFPD receive the same services delivered to other STAR+PLUS Home and Community Based Services (HCBS) program individuals.

 

3522 Screening Criteria for Money Follows the Person Demonstration Eligibility

Revision 20-1; Effective March 16, 2020

 

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

  • reside continuously in an institutional setting for at least 90 days prior to the STAR+PLUS HCBS eligibility date and be enrolled from a Medicaid certified nursing facility (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 individual or individual's family member;
    • an apartment with an individual lease that includes living, sleeping, bathing and cooking areas in which the individual or family member has domain;
    • Assisted Living (AL) apartment (Service Code 19);
    • Residential Care apartment (Service Code 19A); and
    • Adult Foster Care (AFC) home (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, signed by the individual or authorized representative (AR) and MCO staff, after explanation of MFPD and prior to delivery of services.

*The MCO must include the AR in the actual transition planning, if applicable.

 

3522.1 Screening for 90-Day Qualifying Institutional Stay

Revision 20-1; Effective March 16, 2020

 

For purposes of the Money Follows the Person Demonstration (MFPD), an institutional setting is defined as a nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), hospital or state hospital. The 90-day qualifying institutional stay may be met by a continuous stay in a combination of the settings. See also Section 3525, Documentation of the 90-Day Qualifying Institutional Stay Required for MFPD Eligibility in the STAR+PLUS HCBS Program.

Example: An MFPD individual resided continuously in an NF for 30 days, in a hospital for 60 days and then re-entered the NF for another 30 days. This would meet the 90-day institutional residency requirement for MFPD.

The individual does not have to reside in the NF or other institution for 90 days at the time they indicate a desire to transition to the community. The individual meets the screening criteria if it appears likely they will reside in an NF or other institution for at least 90 days prior to the discharge date from the NF.

 

3522.2 Program Support Unit Staff Verification of 90-Day Qualifying Institutional Stay

Revision 20-1; Effective March 16, 2020

 

Program Support Unit Staff (PSU) must verify the 90-day residency requirements for eligibility in the Money Follows the Person Demonstration (MFPD). To verify, PSU staff may:

  • use Minimum Data Set (MDS) information, available on the Texas Medicaid & Healthcare Partnership (TMHP) website;
  • view the Service Authorization System Online (SASO) NF records (Service Code 1);
  • contact the NF for admission dates; or
  • as a last resort, obtain confirmation from the individual.

PSU staff communicate to managed care organization (MCO) staff that the individual is potentially eligible for MFPD by completing the MFPD qualifying begin and end dates in Section A, Item 20, Qualifying Dates, on Form H3676, Managed Care Pre-Enrollment Assessment Authorization.

 

3523 Enrollment in Money Follows the Person Demonstration

Revision 20-1; Effective March 16, 2020

 

Individuals who meet the eligibility requirements and choose to enroll in the Money Follows the Person Demonstration (MFPD) must be designated by Program Support Unit (PSU) staff, according to STAR+PLUS Program Support Unit Operational Procedures Handbook Section 9480, MFPD for STAR+PLUS HCBS Program Applicant, in the Service Authorization System Online (SASO), using the following procedures:

  • Enrollment Record — Enrolled from Field: Choose "12 — Money Follows the Person.”
  • Service Authorizations:
    • Force Box — Check the Force box for each service authorization.
    • Fund Type — Choose "19MFP-Money Follows the Person." This code applies only to MFPD recipients.
    • Force Comment — Enter "MFP Demonstration Member" and select "Force."

Fund Type "19MFP-Money Follows the Person" must be selected for the first individual service plan (ISP) period of participation in MFPD. This fund type is removed after the MFPD entitlement period is over or if the individual withdraws from MFPD. See Section 3524, Money Follows the Person Demonstration Entitlement Period Tracking.

PSU staff must maintain a list of MFPD participants. This list must contain the following:

  • Individual’s name;
  • Medicaid identification (ID) number; and
  • ISP start and end date.

The individual may withdraw from MFPD at any time by informing the managed care organization (MCO) service coordinator. To inform PSU staff of the withdrawal, the MCO service coordinator uploads Form H2067-MC, Managed Care Program Communications, to TXMedCentral, indicating withdrawal from MFPD. Although MFPD eligibility may end upon withdrawal from MFPD, the individual continues to receive STAR+PLUS Home and Community Based Services (HCBS) program services if all STAR+PLUS HCBS eligibility criteria are met.

 

3524 Money Follows the Person Demonstration Entitlement Period Tracking

Revision 20-1; Effective March 16, 2020

 

Money Follows the Person Demonstration (MFPD) individuals are entitled to 365 days of participation in MFPD. Time spent in an institutional setting does not count toward the 365-day entitlement period; therefore, tracking is required to ensure MFPD individuals receive the full 365-day entitlement period.

The entitlement period begins the date the MFPD individual is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program.

Example: The individual chooses to participate in MFPD and is 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 individual is institutionalized for 10 days in April 2020, the MFPD entitlement period is suspended during the period of institutionalization and resumes when they return to the community until the end of the 365-day entitlement period. In this example, the MFPD entitlement period ends on June 10, 2020, which is after the ISP end date of May 31, 2020.
  • If the MFPD individual 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.

Tracking is required to ensure MFPD individuals receive the full 365-day entitlement period unless the individual withdraws from MFPD. The MCO is responsible for tracking the MFPD entitlement period. Once the 365-day entitlement period has passed, the MCO is responsible for uploading Form H2067-MC to TxMedCentral in the MCO folder to inform PSU staff of the date the individual's entitlement period ended.

It is essential that complete and accurate records are maintained because MFPD tracking is subject to audit by the Centers for Medicare and Medicaid Services (CMS).

 

3525 Documentation of the 90-Day Qualifying Institutional Stay Required for MFPD Eligibility in the STAR+PLUS HCBS Program

Revision 20-1; Effective March 16, 2020

 

The individual's date of entry and date of discharge from a hospital, nursing facility (NF) or other institutional setting are included in the number of days the individual is institutionalized for purposes of the 90-day qualifying institutional stay required for the Money Follows the Person Demonstration (MFPD). Program Support Unit (PSU) staff must check the Service Authorization System Online (SASO) for verification of residence in qualified institutional settings. This may include stays in a combination of applicable settings, which include:

  • Service Group (SG) 1, Service Code (SC) 1, NF — Daily care;
  • SG 5, SC 1, State Operated Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID);
  • SG 6, SC 1, Non-State Operated ICF/IID; and
  • SG 4, SC 1, State Supported Living Centers.

PSU staff must send Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO), documenting MFPD 90-day qualifying begin and end dates. Institutional stays for the 90 days prior to the eligibility date must be documented even if it appears the individual does not meet the criteria.

If the individual is currently residing in a qualified institutional setting at the time Form H2067-MC is sent to the MCO, enter the begin date of coverage and use "ongoing" as the end date.

SASO records do not include any possible hospitalizations, which also count toward the 90-day requirement. The MCO will determine if the individual was in a hospital directly before the begin date on Form H2067-MC. The MCO will also determine whether the 90-day residency requirement for MFPD eligibility has been met once the discharge date from the NF is known.

Similarly, if the individual has a gap in institutional residency, the MCO will evaluate MFPD eligibility by checking for possible hospitalizations prior to the NF stay or during the gap period, as well as considering the discharge date from the NF.

 

3530 High/Complex Needs Members

Revision 18-2; Effective September 3, 2018

 

 

 

3531 Designation of High Needs Members

Revision 18-2; Effective September 3, 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 they meet the MCO's MSHCN assessment criteria, and to determine whether the member requires 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 a 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 identification and 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 19-1; Effective June 3, 2019

 

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.

 

3600 Ongoing Service Coordination

Revision 19-1; Effective June 3, 2019

 

Based on the needs of the STAR+PLUS Home and Community Based Services (HCBS) program member, the managed care organization's (MCO's) ongoing service coordination responsibilities could include:

  • revising the individual service plan (ISP) as necessary to meet the needs of the member, responding to service plan change requests and responding to requests for additional services such as adaptive aids, emergency response services, respite or requests for service suspension;
  • coordinating and consulting with MCO-contracted providers regarding delivery of services;
  • reminding the member to complete and return Medicaid renewal eligibility documents sent by Program Support Unit (PSU) staff or the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • monitoring services delivered to members, evaluating the adequacy and appropriateness of the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program, and documenting monitoring activities;
  • assisting the member in accessing and using community, Medicare, family and other third-party resources (TPR);
  • assisting with crisis intervention; and
  • responding to situations of potential denial of an active member whose ISP costs exceed the individual's assessed cost limit, including requesting a re-evaluation of need, meeting with the interdisciplinary team and administrative staff, and coordinating other services before termination of the STAR+PLUS HCBS program.

 

3610 Revising the Individual Service Plan

Revision 21-2; Effective August 1, 2021

 

It may be necessary to revise the individual service plan (ISP) within the ISP period due to changes in the needs of the member or changes in the services offered or emergency situations. The managed care organization (MCO) documents revision to the ISP on Form H1700-1, Individual Service Plan. A revised ISP is not submitted to the Program Support Unit (PSU) via TxMedCentral, but is kept in the member's case record.

 

3611 MCO Required Notifications from the Provider

Revision 18-2; Effective September 3, 2017

 

The provider must notify the managed care organization (MCO) when one or more of the following circumstances occur:

  • the member leaves the service area for more than 30 days;
  • the member has been legally confined in an institutional setting. An institution includes legal confinement, an acute care hospital, state hospital, rehabilitation hospital, state supported living center, nursing home or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
  • the member is not financially eligible for Medicaid benefits;
  • providers have refused to serve the member on the basis of a reasonable expectation that the member's medical and nursing needs cannot be met adequately in the member's residence;
  • the member or someone in the member's home refuses to comply with mandatory program requirements, including the determination of eligibility and/or the monitoring of service delivery;
  • the member fails to pay her or his qualified income trust (QIT) copayment;
  • the situation, member or someone in the member's home is hazardous to the health and safety of the service provider, but there is no immediate threat to the health and safety of the provider;
  • the member or someone in the member's home openly uses illegal drugs or has illegal drugs readily available within sight of the service provider; or
  • the member requests that services end.

 

3611.1 Immediate Suspension of Services

Revision 20-1; Effective March 16, 2020

 

If the member or someone in the member's place of residence exhibits behavior that results in imminent danger to the health and safety of service providers or others, the provider must verbally inform the managed care organization (MCO) by the following business day and follow up with written notification to the MCO within two business days of verbal notification. The written notification must include a detailed description of the member’s behavior and how it impaired the provider’s ability to safely provide services to the member.  Upon notification of suspected abuse, neglect or exploitation, the MCO must ensure an immediate report is made to the Texas Department of Family and Protective Services (DFPS) and may notify the police and immediately suspend services, as needed.

The MCO must provide written notice of suspension of service to the member, as stated in the Uniform Managed Care Manual (UMCM) Chapter 3.21, including an explanation of the member’s right to request an MCO Internal Appeal. The MCO must inform members that they have the right to access the State Fair Hearing process only after exhausting the MCO Internal Appeal System provided by the MCO. The written notification must also specify the reason for the suspension, the effective date and the regulatory reference, such as 1 Texas Administrative Code (TAC), Section 353.203(1)(D)(iv), relating to Member Bill of Responsibilities and the responsibility to treat providers and staff with respect.

The MCO must make efforts to resolve the situation, as appropriate for the level of danger, and document such efforts. The MCO must document whether the behavior is related to a developmental, intellectual, or physical disability or behavioral health condition. If the suspension of services constitutes a threat to the health and safety of the individual, then community alternatives or placement in an institutional setting must be offered and facilitated by the MCO.

With prior authorization by the MCO, the provider may continue providing services to assist in the resolution of the situation. If it is not satisfactorily resolved, then the MCO must follow the established procedures for denial of services located in UMCM Chapter 3.21 or disenrollment from managed care, located in UMCM Chapter 11.5. Services do not continue during the appeal process.

 

3611.2 Required Notification of Service Denial from the Managed Care Organization

Revision 19-1; Effective June 3, 2019

 

If the managed care organization (MCO) determines that documentation supports initiation of denial, the MCO provides written notification of denial to the member within five business days.

The MCO's denial notice must specify the reason for denial, the effective date of the denial, the regulatory reference and provide written notice of the right to appeal. The MCO forwards a copy of the denial notice to the provider within two business days.

If the member appeals the notification of denial within the 10-day adverse action period, the MCO must continue the STAR+PLUS Home and Community Based Services (HCBS) program until notification of the decision by the state fair hearings officer. The MCO must not reduce the STAR+PLUS HCBS program until the outcome of the state fair hearing is known.

 

3620 Reassessment

Revision 18-2; Effective September 3, 2018

 

 

 

3621 Reassessment Procedures

Revision 21-2; Effective August 1, 2021

 

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is entered into the Service Authorization System Online (SASO) annually. PSU staff:

  • check TxMedCentral to determine if the managed care organization (MCO) has submitted Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page, before the ISP end date;
  • verify the SASO case record has an approved medical necessity and level of care (MN/LOC) (both must have the same end date as the ISP being registered; if not, extend the MN/LOC record through the end of the ISP being registered);
  • confirm ongoing Medicaid eligibility;
  • verify continuing enrollment in SASO reflects any plan change;
  • verify the ISP is within the cost limit;
  • determine if the ISP was submitted on time and if:
    • on time, enters service group (SG) 19 service code (SC) 12;
    • not on time, enters SG 19 SC 13 for the month(s) for which the ISP was late and SG 19 SC 12 for the remaining ISP period; and
  • enter the ongoing ISP in SASO within five business days of receipt, not to exceed the ISP end date.

The Supplemental Security Income (SSI)-denied Medicaid program types referenced in Section 3330, STAR+PLUS Members Requesting an Upgrade to the STAR+PLUS Home and Community Based Services (HCBS) Program, do not change in the Texas Integrated Eligibility Redesign System (TIERS) either during the initial or annual review by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. As part of reassessment procedures, PSU staff will remain responsible for confirming ongoing Medicaid eligibility, but is not required to request MEPD test an individual for the additional criteria, or request a change in the Medicaid program type.

If the reassessment ISP is being submitted due to the participant's timely appeal of a STAR+PLUS HCBS program denial, PSU staff enter the information from the old ISP, extending the end date an additional four months. Services continue using this ISP until a decision is received from the hearing officer. At that time, changes are made, if necessary, to comply with the hearing officer's decision.

 

3621.1 Individual Service Plan Expiring Report

Revision 20-2; Effective October 1, 2020

 

Program Support Unit (PSU) staff and managed care organizations (MCOs) will review the Individual Service Plan (ISP) Expiring Report for the STAR+PLUS Home and Community Based Services (HCBS) program on a monthly basis to ensure annual reassessments are conducted timely. The ISP Expiring Report lists the STAR+PLUS HCBS program members with ISPs that will expire within 90 days from the date of the report.

PSU staff must email the ISP Expiring Report to the MCOs five business days prior to the monthly conference call with PSU staff. The MCOs must provide a written status update  for all STAR+PLUS HCBS program members who have ISPs expiring within 45 days. The MCOs must return the status update to PSU staff within two business days prior to the monthly conference call. Although the report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update.

 

3622 Notification Requirements

Revision 19-1; Effective June 3, 2019

 

If the member continues to meet STAR+PLUS Home and Community Based Services (HCBS) program requirements, it is not necessary to send Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services. If the member does not meet STAR+PLUS HCBS program requirements, Program Support Unit (PSU) staff must, within two business days of notification:

  • send Form H2065-D to the member indicating why the case is being terminated;
  • upload a copy of Form H2065-D in TxMedCentral to the XXXSPW folder using the appropriate naming convention; and
  • after the effective date of the action on Form H2065-D, send a copy of Form H2065-D to Enrollment Resolution Services (ERS), if applicable.

If no appeal is filed, ERS disenrolls the member from STAR+PLUS effective the date of the action on Form H2065-D.

If the member files an appeal timely, PSU staff, within two business days of notification:

  • send Form H1746-A, MEPD Referral Cover Sheet, for cases in the Centralized Representation Unit, which forwards the information to the appropriate Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • upload Form H2067-MC, Managed Care Programs Communication, in TxMedCentral to the XXXSPW folder, using the appropriate naming convention, informing the MCO to continue services due to the timely appeal (if services have already ended, the MCO reinitiates services immediately);
  • extend the end date of the current ISP an additional four months; and
  • send an email to ERS on medical assistance only (MAO) cases as notification that a timely appeal was submitted and enrollment should remain open.

ERS, within 10 days of receiving the fair hearings officer's decision, carries out the decision. See Section 4234, Hearing Decision.

 

3623 STAR+PLUS Home and Community Based Services Program Eligibility Date on Form H2065-D

Revision 18-2; Effective September 3, 2018

 

Program Support Unit (PSU) staff must adhere to the following policy when establishing the eligibility date for STAR+PLUS Home and Community Based Services (HCBS) program cases on Form H2065-D, Notification of Managed Care Program Services. The effective date varies. The possible scenarios include:

  • upgrades and interest list releases;
  • members transitioning out of children's programs; and
  • transfers from a nursing facility (NF) using Money Follows the Person (MFP).

 

3623.1 Upgrades and Interest List Releases

Revision 19-1; Effective June 3, 2019

 

The start of care (SOC) date for a STAR+PLUS Home and Community Based Services (HCBS) program applicant being released from the interest list or a member requesting/being processed for an upgrade is based on the:

  • Medicaid eligibility effective date;
  • date the approved and valid medical necessity and level of care (MN/LOC) was submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Long-Term Care Online Portal; and
    Note: A valid MN does not exceed 120 days from the date of Texas Medicaid and Healthcare Partnership (TMHP) approval. If MN exceeds 120 days from date of TMHP approval, PSU staff must complete Form H2067-MC, Managed Care Programs Communication, advising the MCO, and requesting the MCO process a significant change in condition to the MN. PSU staff must upload Form H2067-MC to TxMedCentral in the MCO’s SPW folder.
  • date the member's individual service plan (ISP) was uploaded to TxMedCentral.

Program Support Unit (PSU) staff determine the eligibility and effective date based on the later of the above dates. If the date falls on the first day of the month, the eligibility and ISP effective date on Form H2065-D, Notification of Managed Care Program Services, is the first day of that month. If the date falls between the second and the last day of the month, the eligibility and ISP effective date is the first date of the following month.

 

3623.2 Members Transitioning Out of Children's Programs

Revision 19-1; Effective June 3, 2019

 

The eligibility and the individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transitioning out of the programs below is the 1st of the month following their 21st birthday:

  • Medically Dependent Children Program (MDCP)
  • The Texas Health Steps Comprehensive Care Program (CCP)/Private Duty Nursing or Prescribed Pediatric Extended Care Center

Note: Depending on eligibility requirements, some members may continue to receive services except MDCP, through STAR Health until age 22.  In this scenario, the eligibility and ISP effective date is the 1st of the month following their 22nd birthday.

 

3623.3 Money Follows the Person Nursing Facility Releases

Revision 19-1; Effective June 3, 2019

 

The individual service plan (ISP) effective date on Form H2065-D, Notification of Managed Care Program Services, for members transferring from nursing facilities (NFs) to the STAR+PLUS Home and Community Based Services (HCBS) program via the Money Follows the Person (MFP) process is the date of discharge. The STAR+PLUS eligibility date on Form H2065-D for members transferring from NFs to the STAR+PLUS HCBS program through the MFP process is the date used on the initial Form H2065-D. Service Authorization System Online (SASO) registration for MFP releases from NFs must occur as follows:

  • NF Service Group 1 SAS registrations must be closed the day before the discharge.
  • STAR+PLUS HCBS program Service Group 19 SAS ISP period. The effective date on Form H2065-D is the date of discharge.

 

3630 Denial or Termination

Revision 21-1; Effective May 1, 2021

 

An applicant or member may be denied or terminated from the STAR+PLUS Home and Community Based Services (HCBS) program if they do not meet the eligibility criteria outlined in Title 1 Texas Administrative Code (TAC) §353.1153 or any other applicable state or federal laws. All applicants or members must receive adequate notice of their denial or termination, including the reason for their denial or termination, and the right to a state fair hearing.

 

 

3631 Ten Business Day Adverse Determination Notification

Revision 21-1; Effective May 1, 2021

 

Texas Health and Human Services Commission (HHSC) is required to send a denial or termination notice to the member at least 10 business days before the adverse action effective date. The member must be given the full 10 business day adverse action period to allow the applicant or member time to file an appeal. Managed care organizations must continue to provide services as required by Title 42 Code of Federal Regulations (CFR), Subpart E, Section 431.230, Maintaining services.

The 10-day adverse action period is extended based on whether the 10th day of the period is a Saturday, Sunday or legal holiday. A legal holiday that falls in the middle of the 10-day adverse action period does not require the period to be extended. Legal holidays do not include holidays when HHSC offices are officially open, even with limited workforce.

The full adverse action period may be waived if the member signs a statement to waive the adverse action period. Other situations in which an adverse action period is not required can be found in Title 42 CFR, Subpart E, §431.213, Exceptions from advanced notice.

 

 

3632 STAR+PLUS Home and Community Based Services (HCBS) Denial/Termination Reasons

Revision 21-1; Effective May 1, 2021


 
Program level denials or terminations are initiated when the applicant or member does not meet one or more STAR+PLUS HCBS eligibility criteria.

STAR+PLUS HCBS may be denied or terminated for the following reasons, which will be included on Form H2065-D, Notification of Managed Care Program Services:

  • Death;
  • Institutional Stay;
  • Member Request;
  • Medicaid Financial Eligibility;
  • Medical Necessity/Level of Care (MN/LOC);
  • Exceeding the ISP Cost Limit;
  • Inability to Locate Member;
  • Not Requiring At Least One Waiver Service; or
  • Other Reasons.

If the managed care organization (MCO) is made aware of a reason an applicant or member must be denied or terminated from the STAR+PLUS HCBS program, the MCO must:

  • submit a request for denial or termination to Program Support Unit (PSU) staff, including notification of the reason for the denial, on Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in accordance with the conventions identified in the Uniform Managed Care Manual Chapter 16.2; and
  • monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal and TxMedCentral for denial notices issued by PSU staff.

If PSU staff receive a denial or termination request from the MCO or learn of an applicant’s or member’s ineligibility for STAR+PLUS HCBS from Managed Care Compliance Operations (MCCO), Enrollment Resolution Services (ERS), monthly reports or other reliable sources, within two business days of notification, PSU staff will:

  • mail the member Form H2065-D;
  • upload Form H2065-D to TxMedCentral in the MCO’s SPW folder; and
  • notify Medicaid for the Elderly and People with Disabilities (MEPD) staff, as appropriate.

 

3632.1 Denial or Termination Due to Death

Revision 21-1; Effective May 1, 2021


 
STAR+PLUS Home and Community Based Services (HCBS) must be terminated upon verification of the death of a member.

Program Support Unit (PSU) staff will not upload Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral for applicant or member deaths.  

Managed care organizations must notify the family of their responsibility to communicate the member’s death to the Social Security Administration (SSA).

 

3632.2 Denial or Termination Due to Institutional Stay

Revision 21-1; Effective May 1, 2021

 

STAR+PLUS Home and Community Based Services (HCBS) must be terminated when a member resides in a nursing facility (NF) for 90 days or more.

Program Support Unit (PSU) staff will terminate the member from the STAR+PLUS HCBS program by the end of the month in which the 90th day occurred.

 

3632.3 Denial or Termination Due to Member Request

Revision 21-1; Effective May 1, 2021

 

STAR+PLUS Home and Community Based Services (HCBS) must be denied or terminated when the managed care organization (MCO) is made aware that an applicant or member no longer chooses to participate in the STAR+PLUS HCBS program.

 

3632.4 Denial or Termination of Medicaid Financial Eligibility

Revision 21-1; Effective May 1, 2021

 

An applicant’s or member's eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program is dependent on financial eligibility determined by the Social Security Administration (SSA) for Supplemental Security Income (SSI) or Medicaid for the Elderly and People with Disabilities (MEPD) for medical assistance only (MAO) program requirements. STAR+PLUS HCBS must be denied or terminated when SSA or MEPD staff determine the applicant or member does not meet financial eligibility requirements. The applicant or member is notified of their denial or termination of financial eligibility by SSA staff for SSI or MEPD staff for MAO. The applicant or member may appeal the decision using SSA or MEPD processes, as appropriate.

 

3632.5 Denial or Termination of MN/LOC

Revision 21-1; Effective May 1, 2021

 

An applicant or member must meet a nursing facility level of care to be eligible for the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) must assess the applicant’s or member’s level of care by completing the Medical Necessity and Level of Care (MN/LOC) Assessment and obtaining a physician’s signature.

Note: If the MCO does not receive a signed copy of the physician’s signature page within five business days of the initial request to the applicant’s or member’s physician, the MCO must make at least three additional attempts to obtain the signature. If unsuccessful, the MCO must contact the applicant or member for assistance in obtaining the required signature. If the MCO needs additional time beyond 45 days to make the required contacts to obtain the physician’s signature, the MCO must notify Program Support Staff (PSU) staff.

If an MCO is unable to obtain the physician’s signature required to make an eligibility determination or if the MN/LOC Assessment is denied, PSU staff will deny or terminate STAR+PLUS HCBS program eligibility for the applicant or member.

When the MN/LOC Assessment status is "MN Denied" in the Texas Medicaid & Healthcare Partnership (TMHP) Long-term Care (LTC) Online Portal, the STAR+PLUS HCBS program applicant's or member's physician has 14 business days to submit additional information. Once an MN/LOC Assessment is in "MN Denied" status, several actions may occur:

  • MN Approved: The status changes to "MN Approved" if the TMHP physician overturns the denial because additional information is received.
  • Overturn Doctor Review Expired: The status changes to "Overturn Doctor Review Expired" when the 14-business-day period for the TMHP physician to overturn the denied MN has expired and no additional information was submitted for the physician review or the additional information submitted was not enough to overturn the denial. The “Overturn Doctor Review Expired” status remains unless the applicant or member requests a state fair hearing.
  • Doctor Overturn Denied: The status may change to "Doctor Overturn Denied" when additional information is received but the TMHP physician does not believe the information submitted is sufficient to approve MN. The "Doctor Overturn Denied" status remains unless the applicant or member requests a state fair hearing.

PSU staff will not mail Form H2065-D to deny STAR+PLUS HCBS eligibility until after 14 business days from the date the "MN Denied" status appears in the TMHP LTC Online Portal. After the 14-business-day period has expired, PSU staff will send Form H2065-D to deny services if the TMHP LTC Online Portal status is “Overturn Doctor Review Expired” or “Doctor Overturn Denied.”

 

3632.6 Denial or Termination Due to Exceeding the ISP Cost Limit

Revision 21-1; Effective May 1, 2021


 
The managed care organization (MCO) must consider all available support systems when determining whether the STAR+PLUS Home and Community Based Services (HCBS) individual service plan (ISP) adequately meets the needs of the applicant or member.

As part of the individual service planning process, the MCO must establish an ISP where the total cost of services does not exceed the individual’s cost limit or resource utilization group (RUG) value assigned by Texas Medicaid & Healthcare Partnership (TMHP). When a STAR+PLUS HCBS applicant’s or member’s service needs exceed their assigned cost limit, the MCO must notify Program Support Unit (PSU) staff and request denial of the STAR+PLUS HCBS program, maintaining appropriate documentation to support the denial. The MCO's documentation of this type of denial must demonstrate that the ISP, including both the STAR+PLUS HCBS program and non-STAR+PLUS HCBS program services, allowed within the RUG cost limit do not adequately meet the needs of the applicant or member.

 

3632.7 Denial or Termination Due to Inability to Locate the Member

Revision 21-1; Effective May 1, 2021


 
The managed care organization (MCO) must make at least three efforts to contact members who request or are receiving STAR+PLUS Home and Community Based Services (HCBS) by telephone. The telephone contact attempts must be made on separate days, over a period of no more than five business days, and must be made at a different time of day upon each attempt.

If an MCO is unable to reach a member or a member’s legally authorized representative (LAR) by telephone, the MCO must mail written correspondence to the member and member’s LAR explaining the need to contact the MCO and requesting that the member or member’s LAR contact the MCO as soon as possible.

If the MCO has not made any contact with the member or LAR 15 business days after sending the written correspondence, the MCO must attempt to contact the member or LAR in person by visiting the member’s address on file.

If the MCO is still unable to locate the member and wishes to request a denial or termination, the MCO must include all documented attempts when sending notification to Program Support Staff (PSU) staff.

 

3632.8 Denial or Termination Due to Not Requiring at Least One Waiver Service

Revision 21-1; Effective May 1, 2021

 

STAR+PLUS Home and Community Based Services (HCBS) must be denied or terminated if the managed care organization assesses the applicant or member and the results indicate the applicant or member does not have a need that requires one or more of the STAR+PLUS HCBS program services. 

 

3632.9 Denial or Termination for Other Reasons

Revision 21-1; Effective May 1, 2021

 

If the managed care organization (MCO) wants to request a denial or termination for a reason not listed above, the MCO must notify Program Support Unit staff of the STAR+PLUS Home and Community Based Service program denial or termination request. The notification must include detailed information that supports the denial or termination request.

 

 

3633 Disenrollment

Revision 21-1; Effective May 1, 2021

 

Texas Health and Human Services Commission (HHSC) conducts member disenrollment activities. Although a STAR+PLUS member may request disenrollment from managed care, membership in managed care is mandatory, with limited exceptions. See Chapter 533 of the Government Code and Title 1 of the Texas Administrative Code, Sections 353.601 and 353.603 (related to STAR+PLUS Medicaid managed care), and Section 353.403 (related to enrollment and disenrollment standards for Medicaid managed care).

Members who receive HHSC approval to disenroll from managed care and who maintain Medicaid eligibility may continue to receive services available through fee-for-service (FFS) Medicaid. All members who transition to FFS Medicaid lose any value-added services provided by the managed care organization (MCO). Those members who were receiving services under STAR+PLUS Home and Community Based Services (HCBS) may also lose some, if not all, of their HCBS waiver services in the transition to FFS Medicaid.

 

3633.1 Disenrollment Request by MCO

Revision 21-1; Effective May 1, 2021


A managed care organization (MCO) has a limited right to request a member be disenrolled from the MCO’s plan without the member’s consent pursuant to 42 Code of Federal Regulations §438.56. Refer to the HHSC Uniform Managed Care Manual, Chapter 11.5, Medicaid Managed Care Member Disenrollment Policy, for procedures to request the involuntary disenrollment of members.

Section 4000, Complaints, Internal MCO Appeals and State Fair Hearings

Section 4000, Complaints, Internal MCO Appeals and State Fair Hearings Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

Revision 21-2; Effective August 1, 2021

 

 

4100 Managed Care Organization Procedures

Revision 11-4; Effective December 1, 2011

 

The managed care organization (MCO) must develop, implement and maintain a member complaint and appeal system that complies with the requirements in applicable federal and state laws and regulations, including Code of Federal Regulations 42, §431.200, 42 CFR Part 438, Subpart F, Grievance System, and the provisions of Texas Administrative Code 1, Chapter 357, relating to Medicaid managed care organizations.

The MCO's complaint and appeal systems must include:

  • a complaint process;
  • an appeal process; and
  • access to the Health and Human Services Commission fair hearing process.

 

 

4110 MCO Complaint Procedures

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission's (HHSC) Uniform Managed Care Contract Terms and Conditions, Attachment A, defines a complaint as:

"an expression of dissatisfaction expressed by a Complainant, orally or in writing to the managed care organization (MCO), about any matter related to the MCO other than an Action. As provided by 43 CFR §438.400, possible subjects for Complaints include, but are not limited to, the quality of care of services provided, and aspects of interpersonal relationships, such as rudeness of a provider or employee, or failure to respect the Medicaid Member's rights."

The complaint procedure does not apply to situations described in "Appeal Procedures."

When a managed care organization (MCO) member wants to file a complaint, he or she must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO must provide a designated member advocate to assist the member in using the complaint system. The advocate must assist members in writing or filing a complaint, and monitor the complaint throughout the process until the issue is resolved.

If the member is not satisfied with the outcome of the MCO complaint process, he or she sends a written request to HHSC to investigate the complaint. The request is sent to:

Texas Health and Human Services Commission Managed Care Operations – STAR+PLUS Mail Code H-320 P. O. Box 13247 Austin, TX 78711

If a STAR+PLUS member contacts any HHSC employee with a complaint regarding an agency licensed by HHSC, the member is referred to 1-800-458-9858 to file a regulatory complaint.

Members may also call the Medicaid hotline at 1-800-252-8263 to file a complaint not related to licensure issues.

 

 

4120 MCO Appeal Procedures

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission's Uniform Managed Care Contract Terms and Conditions, Attachment A, defines an appeal as the formal process by which a member or his or her representative requests a review of the managed care organization’s (MCO’s) action. An action is:

  • the denial or limited authorization of a requested Medicaid service, including the type or level of service;
  • the reduction, suspension or termination of a previously authorized service not caused by loss of eligibility;
  • denial in whole or in part of payment for service;
  • failure to provide services in a timely manner;
  • failure of an MCO to act within the time frames set forth in the contract and 42 Code of Federal Regulations (CFR) §438.408(b); or
  • for a resident of a rural area with only one MCO, the denial of a Medicaid member's request to obtain services outside of the network.

The member may file an appeal by contacting the MCO following the procedures specified in the MCO's member handbook. The MCO is contractually required to regard any oral or written expression of dissatisfaction or disagreement as a request to file an appeal. The MCO must provide a designated member advocate to assist the member in filing an appeal. The advocate must also assist members by monitoring the appeal throughout the process until the issue is resolved.

During the appeal process, the MCO must provide the member a reasonable opportunity to present evidence and any allegations of fact or law in person, as well as in writing. The MCO must inform the member of the time available for providing this information and that in the case of an expedited resolution, limited time will be available.

The MCO must provide the member and his or her representative the opportunity, before and during the appeal process, to examine the member's case file, including medical records and any other documents considered during the appeal process.

As required by 42 CFR §438.420, the MCO must continue the individual's benefits pending the outcome of the appeal if all the following criteria are met:

  • appeal is filed by the effective date of action;
  • appeal involves termination, suspension or reduction of a previously authorized course of treatment;
  • services were ordered by an authorized provider; and
  • original period covered by the authorization has not expired.

 

 

4121 Expedited MCO Appeals

Revision 11-4; Effective December 1, 2011

 

In accordance with 42 Code of Federal Regulations §438.410, and Uniform Managed Care Contract (UMCC) Attachment B-1, Section 8.2.7.3, the managed care organization (MCO) must establish and maintain an expedited review process for service-related appeals when the MCO determines (for a request from a member) or the provider indicates (in making the request on the member’s behalf or supporting the member’s request) that taking the time for a standard resolution could seriously jeopardize the member’s life or health. The MCO must follow all appeal requirements for standard member appeals as set forth in UMCC Attachment B-1, Section 8.2.7.2, except where differences are specifically noted. The MCO must accept oral or written requests for expedited appeals.

After the MCO receives a request for an expedited appeal, the MCO must notify the member of the outcome of the expedited appeal request within three business days. However, the MCO must complete investigation and resolution of an appeal relating to an ongoing emergency or denial of continued hospitalization:

  • in accordance with the medical or dental immediacy of the case; and
  • not later than one business day after receiving the member's request for expedited appeal.

Members must exhaust the MCO’s expedited appeal process before making a request for an expedited state fair hearing.

Except for an appeal relating to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited appeal may be extended up to 14 calendar days if the member requests an extension or the MCO shows (to the satisfaction of the Health and Human Services Commission (HHSC), upon HHSC’s request) that there is a need for additional information and how the delay is in the member’s interest. If the time frame is extended, the MCO must give the member written notice of the reason for delay if the member did not request the delay.

If the decision is adverse to the member, the MCO must follow the procedures relating to the notice in UMCC Attachment B-1, Section 8.2.7.5. The MCO is responsible for notifying the member of his/her right to access an expedited fair hearing from HHSC. The MCO is responsible for providing documentation to the state and the member, indicating how the decision was made, prior to HHSC’s expedited fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his/her representative for requesting an expedited appeal. The MCO must ensure that punitive action is neither taken against a provider who requests an expedited resolution, nor supports a member’s request.

If the MCO denies a request for expedited resolution of an appeal, the MCO must:

  • transfer the appeal to the time frame for standard resolution; and
  • make a reasonable effort to give the member prompt oral notice of the denial, and follow up within two calendar days with a written notice.

 

 

4200 Appeal Procedures for Program Support Staff

Revision 14-1; Effective March 3, 2014

 

 

 

 

4210 PSU Specialist Procedures

Revision 19-3; Effective December 2, 2019

 

When a request for a fair hearing is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the hearings officer within five calendar days from the date of the request. Upon receipt of the fair hearing request, the PSU specialist completes Form 4800-D, Fair Hearing Request Summary. The PSU specialist sends the form to the regional data entry representative (DER) and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the DER two days to enter the information into the Texas Integrated Eligibility Redesign System.

When PSU staff complete Form 4800-D, all questions in Section 3, Appellant Details Programs, must be answered. In Subsection D, Summary of Agency Action and Citation, staff must always answer “No” to the question, “Is there a good cause for non-timely?” as this question applies only to Texas Works programs.

PSU staff must indicate the Individual Service Plan (ISP) or Individual Plan of Care (IPC) begin and end dates, as applicable, in Section 3.D., Summary of Agency Action and Citation. The begin and end dates must also be mentioned during the fair hearing so the hearings officer is aware of when the ISP or IPC year ends when rendering a decision for STAR+PLUS Waiver.

The Form 4800-D format follows the data entry screens. See the Form 4800-D instructions for more specific directions for completion and transmittal.

 

4211 Designated DER Procedures

Revision 19-3; Effective December 2, 2019

 

Within two calendar days of receipt of Form 4800-D, Fair Hearing Request Summary, the data entry representative (DER) enters the information into the Fair Hearings and Appeals system in the Texas Integrated Eligibility Redesign System. When entry of all information is complete, the system assigns the appeal identification (ID) number. The DER notes the appeal ID number on the bottom of the form and in the designated space on the front of the form, and sends a copy back to the PSU specialist and his supervisor.

When an applicant or member requests a fair hearing, the burden of proof to uphold the PSU decision rests with the PSU. The hearings officer is a neutral party and is restricted by law from presenting the agency’s case. It is crucial that staff complete and organize all fair hearing packets in order to support the agency’s decision.

 

 

4212 Fair Hearings and Appeals Procedures

Revision 14-1; Effective March 3, 2014

 

The Texas Integrated Eligibility Redesign System generates a hearing packet, which includes:

The Program Support Unit (PSU) coordinator and his/her supervisor receive a copy of Form H4800 and Form H4803, identifying the fair hearings officer assigned to the appeal and the date, time and location of the hearing. PSU staff are not expected or required to attend fair hearings.

 

 

4213 Hearing Packet

Revision 21-2; Effective August 1, 2021

 

Use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the fair hearings officer. Be sure documentation on the form clearly states this is a STAR+PLUS Program appeal. The appeal identification number assigned by the Texas Integrated Eligibility and Redesign System must be written on the top of Form H4800-A.

Use Form 4800-D, Fair Hearing Request Summary, to record the names, titles, addresses and telephone numbers of all persons, or their designees, who should attend the hearing. For appeal issues related to service delivery, enter the names of the designated managed care organization (MCO) staff and the designated backup. Program Support Unit (PSU) staff should contact the MCO if there is doubt as to who should be listed on Form 4800-D.

Depending on the issue being appealed, the following staff must attend:

  • MCO and Texas Medicaid & Healthcare Partnership (TMHP) (for medical necessity/level of care (MN/LOC) denials);
  • MCO (for denials of individual service plans (ISPs) over the cost ceiling); and
  • Medicaid for the Elderly and People with Disabilities (MEPD) (for financial denials).

All related documentation necessary to support the decision taken on an Home and Community-based (HCBS) STAR+PLUS Waiver (SPW) case must be sent to the fair hearings officer within 10 business days prior to the hearing. Each entity involved in the fair hearing is responsible for preparing its packet and forwarding it to both the hearings officer identified on Form H4803, Notice of Hearing, and the appellant. Be sure documentation on the form clearly states this is a STAR+PLUS Waiver Program appeal. All documentation must be neatly and logically organized, and all pages numbered.

Examples of additional information and who is responsible for submitting that information to the state fair hearings office include, but are not exclusively limited to:

  • MCO:
    • MCO policy handbook, STAR+PLUS Handbook and/or Uniform Managed Care Contract/Uniform Managed Care Manual;
    • summary of events;
    • other documentation supportive of the decision, such as documentation of telephone calls, visit summaries, etc.; and
    • copies of the signed Form H1700-1, Individual Service Plan, and Form H1700-3, Individual Service Plan – Signature Page, and all relevant attachments;
  • MEPD:
    • documentation supportive of the financial decision, including official documentation forms, telephone calls, etc.; and
    • a copy of the original signed denial form;
  • TMHP:
    • a copy of the MN/LOC; and
    • other documentation supporting the decision; and
  • PSU — a copy of the original signed Form H2065-D, Notification of Managed Care Program Services (if available, use the signed copy of the form returned by the applicant/member when the appeal was filed).

After the data entry representative (DER) has added information from Form 4800-D into the Texas Integrated Eligibility Redesign System (TIERS), PSU may learn of subsequent changes such as address changes, withdrawal forms or additional supporting documents needed for a fair hearing. When this occurs, PSU staff complete Form H4800-A with the updated information and submit it to the designated DER who will check TIERS to identify if a fair hearings officer has been assigned to the case. In the event the participant updates need to be communicated to the fair hearings officer, PSU staff complete and forward Form 4800-D to the DER.

If a fair hearings officer is not yet assigned, the DER must wait until one is assigned to send the additional information. When sending information, the DER completes the following activities according to the situation:

  • When PSU staff submit Form H4800-A or Form H4800-D to the DER, the DER sends the form(s) directly to the hearings officer’s email address with the appeal ID number in the subject line.
  • If the PSU staff submission to the DER includes additional supporting documentation for an appeal, the DER not only emails Form H4800 to the assigned hearings officer, but also uploads the supporting documentation directly into TIERS. The email sent by the DER must include the appeal ID number in the subject line, as referenced above, and inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded to TIERS.

PSU staff and the DER must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

 

 

4220 Special Procedures for Cases MEPD or TW Determined Financial Eligibility

Revision 14-1; Effective March 3, 2014

 

 

 

 

4221 Centralized Representation Unit

Revision 14-1; Effective March 3, 2014

 

The Health and Human Services Commission (HHSC) Office of Eligibility Services (OES) maintains a Centralized Representation Unit (CRU) to handle all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works (TW) staff. CRU replaces the MEPD specialist in specific steps related to the denial of MEPD applications and ongoing cases. CRU:

  • represents HHSC OES in fair hearings, which includes both TW and MEPD;
  • completes and implements all TW/MEPD case actions based on fair hearing decisions; and
  • coordinates actions required with regional TW/MEPD staff and Program Support Unit (PSU) staff.

PSU staff must coordinate all appeals involving TW/MEPD-related eligibility with CRU. This includes HCBS STAR+PLUS Waiver (SPW) cases. The procedures in Section 4222, Centralized Representation Unit Procedures, must be used to coordinate appeal actions with CRU in cases for which MEPD staff determine financial eligibility.

Staff must remember CRU replaces the local TW/MEPD specialist in the following steps and that notices must not be sent to the local MEPD specialist, except as specified. All correspondence on appeals will go to the CRU supervisor and the CRU administrative assistant.

 

 

4222 Centralized Representation Unit Procedures

Revision 19-3; Effective December 2, 2019

 

Applicants/members may appeal a decision orally, in person or in writing. Program Support Unit (PSU) staff are responsible for completing Form 4800-D, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/member requests a fair hearing. The method in which the form is completed depends on the action being appealed. Staff must determine if the appealed action is:

  • a waiver/service denial (excludes denials based on Texas Works/Medicaid for the Elderly and People with Disabilities (TW/MEPD) denials); or
  • a TW/MEPD financial denial (denials based on a TW/MEPD denial action).

If the appealed action is related to a waiver/service denial, PSU staff complete Form 4800-D, entering the managed care organization contact as the Agency Representative. In the Other Participants field, PSU staff enter the Centralized Representation Unit (CRU) supervisor and CRU administrative assistant. The CRU supervisor and assistant names must be entered by using the Model Office Resources (MOR) Search function. This will assure that all the correct information is populated in the Texas Integrated Eligibility Redesign System (TIERS) and CRU staff will receive the notice of the appeal. Supplemental Security Income recipient appeals are not handled by CRU.

If the appealed action is a TW/MEPD financial denial, staff complete Form 4800-D and enter the name of the CRU supervisor as the agency representative. This information must be entered through the MOR Search function for CRU to receive the hearing information. List the PSU staff name and title in the Other Participants section. The name of the local TW/MEPD specialist is not entered by staff on Form 4800-D for TW/MEPD financial appeals. PSU staff must include staff title, such as PSU specialist or supervisor. Enter the staff email address and include the CRU administrative assistant in Other Participants. Her information must be entered through the MOR Search function.

If this is a TW/MEPD-related appeal, select "Yes" to the question in Section 6 which asks: "Are you an OES Texas Works or MEPD employee?" You are actually responding to this question on behalf of Kristi Rojas, so "Yes" is the correct response. On the Agency Representative page, select "Yes" in the drop-down menu. Failure to answer "Yes" to this item will result in CRU not being notified of the hearing. This paragraph only applies to TW/MEPD financial denials.

When Form 4800-D is sent to the designated data entry representative, PSU staff send an email notification regarding the request for an appeal to CRU. PSU staff will send the email to the HHSC Office of Eligibility Services (OES) Fair Hearings mailbox, which can be found in the Outlook Global Address List search box by typing HHSC OES Fair Hearings. In the subject line of the email, include the following: Request for Continued Benefits-MEPD Appeal ID-XXXXXXX. In an attachment to the email, staff must also include a copy of the notification form sent to the applicant or member.

The email must include:

  • applicant's/member's name;
  • Medicaid number (if available);
  • type of service (HCBS STAR+PLUS Waiver (SPW)); and
  • specific information requesting the TW/MEPD financial case remain active/open during the appeal, if the member appealed in a timely manner and requested continued benefits.

For example, the financial case may need to remain open pending an appeal decision regarding medical or functional eligibility. PSU staff must notify CRU to keep the TW/MEPD case open pending the fair hearing decision.

Upon receipt of notification of an appeal, CRU requests the TW/MEPD evidence packet from the local TW/MEPD specialist and completes any necessary actions required during the appeal process. The CRU supervisor assigns CRU staff to represent TW/MEPD at the hearing, if required, and takes steps to ensure the appropriate TW/MEPD financial case action is taken once a fair hearings officer's decision is rendered.

When a waiver/service denial hearing decision is rendered by the fair hearings officer, the PSU staff entered as "Agency Representative" is notified via email of the decision by the fair hearings officer. Based on the hearing decision, PSU staff determine the appropriate action for the waiver/services according to program-specific time frames. For more information, refer to Section 4500, Hearing Decision Actions.

PSU staff may need to coordinate effective dates of reinstatement with CRU and must email the CRU supervisor (with a copy to the CRU administrative assistant) for the coordination. PSU staff report the implementation of the hearing decision through TIERS on Form 4807-D, Action Taken on Hearing Decision, according to current procedures.

The local TW/MEPD specialist notifies PSU staff if an appeal is filed by TW/MEPD regarding a financial eligibility decision, and refers the TW/MEPD case to CRU to handle during the appeal process. Once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU must notify PSU staff via email of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, staff determine the appropriate action for the waiver/service. The email sent by CRU includes:

  • applicant's/member's name;
  • Medicaid number;
  • a copy of the hearing decision; and
  • the effective or denial date of Medicaid eligibility.

Staff must not put an applicant/member back on waiver/service-specific interest lists while a TW/MEPD denial is in the appeal process. PSU staff must take appropriate action to certify or deny the case, or resume services once the TW/MEPD hearing decision is rendered. The individual may choose to be added back to the waiver/service-specific interest list once staff deny the waiver/service.

 

 

4230 Regional Responsibilities

Revision 14-1; Effective March 3, 2014

 

 

 

 

4231 Uploading the Appeals Evidence Packet into the TIERS Application

Revision 14-1; Effective March 3, 2014

 

All evidence packets must be scanned into the Texas Integrated Eligibility Redesign System (TIERS) Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation (also referred to as the appeals packet) to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

At least 12 business days prior to the fair hearing date, the case manager or Program Support Unit (PSU) specialist must:

  • go to the multi-function office Workcenter and scan in the documentation;
  • save the document by either allowing the default document name or entering a name of the user's choosing;
  • retrieve the scanned document and attach it to an email; and
  • send the document to the regional DER.

Within two business days after receipt, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the TIERS portal and select the Appeals tab, without launching TIERS;
  • ensure the appeal has been entered in TIERS (this requirement must be met before the next step can be completed);
  • select Hearing Evidence Packets Upload and enter the Appeal ID;
  • select Document Type: Agency Evidence Packet (items entered in any other selection will not be included in the evidence packet);
  • select Validate;
  • check the details to ensure the right person has been selected;
  • browse for the document; and
  • select Upload.

Users who make mistakes they are unable to reverse may contact the state office Document Maintenance manager to assist in correcting the error and uploading the appropriate information.

 

 

4232 Presentation of the Hearing Packet

Revision 14-1; Effective March 3, 2014

 

The Texas Integrated Eligibility Redesign System generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The Program Support Unit (PSU) specialist and his/her supervisor receive a copy of Form H4800 and Form H4803, identifying the hearings officer assigned and the date, time and location of the hearing. PSU staff are not expected or required to attend fair hearings.

 

 

4233 Presentation of the Evidence

Revision 14-1; Effective March 3, 2014

 

Documentation contained in the fair hearing packet is not considered in the case decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Ned Flanders. Pages 1-10 contain information relating to the completion of Form H2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the STAR+PLUS Handbook that relates directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form H2065-D, Notification of Managed Care Program Services, which was mailed to the applicant on March 2, 2011."

The fair hearings officer then asks for objections and admits the documents into evidence. If any documents are not admitted, the fair hearings officer explains the reasons for excluding the material. Any documents admitted by the fair hearings officer are considered when a decision is rendered.

 

 

4234 Hearing Decision

Revision 14-1; Effective March 3, 2014

 

After the hearing is held, the fair hearings officer sends a decision letter to the appellant and copies to the Program Support Unit (PSU) specialist and his/her supervisor. If the decision is sustained, the PSU specialist takes the appropriate action. If the member requested continued services during the appeal period, follow procedures as described in Section 4500, Hearing Decision Actions.

If the action is reversed, the fair hearings officer also sends Form H4807, Action Taken on Hearing Decision. The fair hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. The PSU specialist actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System within the 10-day time frame designated by the hearings officer.

 

 

4300 Post Hearing Actions

Revision 14-1; Effective March 3, 2014

 

 

 

 

4310 Action Taken on the Hearing Decision

Revision 19-3; Effective December 2, 2019

 

The Program Support Unit (PSU) specialist completes Form 4807-D, Action Taken on Hearing Decision, recording case actions taken and sends it to his/her supervisor and the designated data entry representative (DER). The PSU specialist must send Form 4807-D within the time frame to allow at least two days for the DER to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, Form 4807-D is completed and sent to the supervisor and DER, providing the reason for the delay. Acceptable reasons are listed on the form; the begin delay date and end delay date must be included. See the instructions for Form 4807-D for detailed information on completion of the form.

 

 

4400 Continuation of Services

Revision 14-1; Effective March 3, 2014

 

 

 

 

4410 Continuation of STAR+PLUS Waiver Services During an Appeal

Revision 15-1; Effective September 1, 2015

 

HCBS STAR+PLUS Waiver (SPW) services must continue until the hearings officer makes a decision regarding the appeal of an active SPW member, if the appeal is filed by the effective date of the action pending the appeal. If an appeal was requested by the effective date of the action, Program Support Unit (PSU) staff must promptly notify the managed care organization (MCO).

SPW services must continue to be provided until the hearings officer renders a decision by posting to TxMedCentral Form H2067-MC, Managed Care Programs Communication.

If the hearings officer's decision will not be made until after the individual service plan (ISP) expiration date, PSU staff must extend the current ISP for four calendar months or until the outcome of the appeal is determined. PSU does not extend the medical necessity/level of care records in the Service Authorization System (SAS). Do not send Form H2065-D, Notification of Managed Care Program Services, to the member notifying of continued eligibility related to the reassessment action taken to continue services until the appeal decision is made.

If an appeal is initially dismissed and subsequently re-opened, the Health and Human Services Commission (HHSC) continues/restarts services pending the appeal outcome, if the member requests continued services. When the hearing officer sets a date for a new hearing, he/she, in effect, voids the prior decision. Because services are continued until a decision is rendered, and the hearing officer is stating there is still a hearing to be held, HHSC continues/re-starts services again.

 

 

4420 Discontinuation of HCBS STAR+PLUS Waiver Services During an Appeal

Revision 14-1; Effective March 3, 2014

 

If the appeal is not filed by the effective date of the action, HCBS STAR+PLUS Waiver (SPW) services continue until the effective date of denial notated on Form H2065-D, Notification of Managed Care Program Services, which is usually the expiration date of the current individual service plan (ISP). If an appeal was not requested by the effective date of the action, the Program Support Unit must complete Form H2067-MC, Managed Care Programs Communication.

  • For Medical Assistance Only (MAO) members, Form H2067-MC is:
    • posted to TxMedCentral to inform the managed care organization (MCO) SPW services must continue until the end of the ISP period or the Medicaid denial date, as notated on Form H2065-D; and
    • emailed to Operations Coordination to disenroll from STAR+PLUS following the disenrollment policy effective the day immediately following the ISP expiration date.
  • For Supplemental Security Income (SSI) members, Form H2067-MC should be posted to TxMedCentral to inform the MCO that SPW services should continue until the end of the ISP period.

SSI members are still enrolled in STAR+PLUS services and are still eligible for State Plan services, which include acute care and long-term services and supports, such as Primary Home Care and Day Activity and Health Services.

 

 

4500 Hearing Decision Actions

Revision 14-1; Effective March 3, 2014

 

 

 

 

 

4510 Sustained Appeal Decisions

Revision 14-1; Effective March 3, 2014

 

When the hearings officer’s decision sustains the denial of HCBS STAR+PLUS Waiver (SPW) services, Program Support Unit (PSU) staff must:

  • notify the member via telephone or letter (if the individual does not have a telephone) of the hearings officer's decision and the termination effective date;
  • notify the managed care organization via Form H2067-MC, Managed Care Programs Communication, to deliver services through the SPW termination effective date if services were continued during the appeal process;
  • terminate SPW (service group 19) services in the Service Authorization System effective the SPW termination effective date (see Section 4511 below);
  • notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist of the hearings officer's decision and the termination effective date for non-Supplemental Security Income (SSI) recipients. MEPD terminates Medicaid eligibility for non-SSI recipients; and
  • notify Managed Care Operations of the hearings officer's decision and the termination effective date for non-SSI recipients. Managed Care Operations disenrolls non-SSI recipients from STAR+PLUS.

PSU must not send another Form H2065-D, Notification of Managed Care Program Services, to notify the member of the sustained denial.

 

 

4511 Sustained Decisions – Termination Effective Dates

Revision 12-3; Effective October 1, 2012

When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the appeal decision is known, the HCBS STAR+PLUS Waiver (SPW) termination effective date will vary depending on the circumstances:

  • In cases where the hearings officer's decision is 30 calendar days or more prior to the end of the individual service plan (ISP) in effect when the appeal was filed, SPW termination is effective at the end of the ISP in effect at the time the appeal was filed. See Example 1.
  • When the hearings officer's decision date is less than 30 calendar days before the end of the ISP in effect when the appeal was filed, the termination effective date is the end of the month that is 30 calendar days from the hearings officer's decision date (the date the order is signed as recorded on Page 1 of Form H4807, Action Taken on Hearing Decision). See Example 2.
  • When the hearings officer's decision date is after the end of the ISP in effect when the appeal was filed, and a new ISP was developed to continue services past the ISP end date until the appeal decision was made, the termination effective date is the end of the month that is 30 calendar days from the hearings officer's decision date (as recorded on Page 1 of Form H4807). See Example 3.
  • If the hearings officer assigns a specific medical necessity (MN)/ISP expiration date not equal to the last day of the month but after the end of the ISP in effect when the appeal was filed, the termination effective date is the end of the month the hearings officer identified as the expiration month. See Example 4.
  • When the hearings officer assigns a specific MN/ISP expiration date equal to the last day of the month, and this date is equal to or after the end of the ISP in effect when the appeal was filed, the termination effective date is the end of that ISP period. See Example 5.
  • If the hearings officer assigns a specific MN/ISP expiration date that is before the end of the MN/ISP in effect when the appeal was filed, the termination effective date is the end of the month of the original MN/ISP expiration date. See Example 6.

Examples

Example Conditions Original MN/ISP Expiration Date New Expiration Date Hearings officer Decision Date Final MN/ISP Expiration Date
1 hearings officer decision is more than 30 days from the original expiration date. 1/31/10 5/31/10 11/30/09 1/31/10
2 hearings officer decision is less than 30 days from the original expiration date. 1/31/10 5/31/10 1/15/10 2/28/10
3 hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/10 5/31/10 2/15/10 3/31/10
4 hearings officer decision assigns a specific expiration date. 1/31/10 5/31/10 hearings officer decision was for MN/ISP to expire on 2/15/10. 2/28/10
5 hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/10 5/31/10 hearings officer decision was for MN/ISP to expire on 2/28/10. 2/28/10
6 hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/10 5/31/10 hearings officer decision was for MN/ISP to expire on 12/31/09. 1/31/10

 

 

4520 Reversed Appeal Decisions

Revision 14-1; Effective March 3, 2014

 

When the hearings officer’s decision reverses the denial of an HCBS STAR+PLUS Waiver (SPW) applicant or member, Program Support Unit staff must:

  • notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, that SPW services are to continue as directed in the decision and to request Form H1700-1, Individual Service Plan — SPW (Pg. 1);
  • send Form H2065-D, Notification of Managed Care Program Services, within two business days to the:
    • SPW member who was terminated at reassessment to notify him the denial decision was reversed and he is eligible for SPW services for the new individual service plan (ISP) year;
    • SPW applicant who was denied at application to notify him of eligibility for SPW services;
    • MCO regarding applicants and the SPW effective date; and
    • Managed Care Operations staff regarding applicants and the SPW effective date and enrollment date;
  • ensure the ISP is registered or updated in the Service Authorization System with the correct effective dates; and
  • notify Medicaid for the Elderly and People with Disabilities, as appropriate, to continue Medicaid eligibility.

 

 

4521 Reversed Decisions – Effective Dates

Revision 19-3; Effective December 2, 2019

 

When the hearings officer’s decision reverses the denial of HCBS STAR+PLUS Waiver (SPW) eligibility, the SPW effective date for:

  • reassessment is one day after the end of the individual service plan in effect when the appeal was filed; and
  • SPW denied at application is the first of the month following the hearings officer's decision recorded on Form H4807, Action Taken on Hearing Decision.

When a fair hearing decision reverses a Program Support Unit (PSU) action but PSU staff cannot implement the fair hearing decision within the required time frame, PSU staff must complete Section C, Implementation Delays, on Form 4807-D, Action Taken on Hearing Decision. Form 4807-D must be submitted within the required time frame.

 

 

4522 New Assessment Required by Fair Hearing Decision

Revision 19-3; Effective December 2, 2019

 

If the hearings officer’s final decision orders completion of a new Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Medical Necessity and Level of Care (MN/LOC) Assessment, the hearing is closed as a result of this ruling. Program Support Unit (PSU) staff must notify the member of the results of the new assessment on Form H2065-D, Notification of Managed Care Program Services. The member may appeal the results of the new assessment. If the member chooses to appeal, PSU staff must indicate in Section 3.D., Summary of Agency Action and Citation, of Form 4800-D, Fair Hearing Request Summary, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision.

If the member requests an appeal of the new assessment and services are continued, the managed care organization (MCO) continues services until the second fair hearing decision is implemented. For example, a STAR+PLUS Waiver (SPW) member is denied medical necessity (MN) at an annual reassessment and requests a fair hearing and services are continued. The MCO would continue services at the level the member was receiving prior to the MN denial. The hearings officer then orders a new MN/LOC Assessment which results in another MN denial. PSU staff send a notice to the member informing him of the MN denial. The member then requests another fair hearing and services are continued pending the second fair hearing decision. The MCO would continue services at the same level services were continued prior to the first fair hearing. If the new assessment results in MN approval but a lower Resource Utilization Group (RUG) level and the member requests a fair hearing due to the lower RUG level, the MCO would continue services at the same level services were continued prior to the first fair hearing.

 

 

4523 Request to Withdraw an Appeal

Revision 14-1; Effective March 3, 2014

 

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. Program Support Unit (PSU) staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts PSU staff regarding the withdrawal, PSU staff must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to PSU staff, PSU staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on a PSU decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify PSU by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw his appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System and a written notice will be sent to participants informing them of the fair hearing cancellation.

 

 

4600 Roles and Responsibilities of HHSC Fair Hearings Officers

Revision 19-3; Effective December 2, 2019

 

The Health and Human Services Commission fair hearings officer:

  • notifies all persons listed on Form 4800-D, Fair Hearing Request Summary, of the date, time and location of the hearing;
  • prepares a final order disposing of a case through withdrawal and sends copies of this order to the appellant and Program Support Unit (PSU) upon written notification from the appellant to withdraw an appeal;
  • conducts the hearing;
  • uses the Texas Medicaid & Healthcare Partnership (TMHP) nurse to determine whether any new medical information introduced at the hearing meets the medical necessity (MN) criteria for nursing facility care;
  • reserves the right to hold a case open after a hearing pending medical review by TMHP physicians;
  • submits a written request for medical review to TMHP for all new medical information presented at a hearing in situations where the TMHP nurse determines the new medical information presented does not meet the MN criteria;
  • renders a decision; and
  • sends a written copy of all hearing decisions to the member/applicant, TMHP and the PSU staff within five days of making the decision.

Administrative review of any hearings officer's decision provided in the fair hearings rules must be initiated by the appellant (applicant/member). Program staff may disagree with the decision; however, the hearings officer's decision is final. Disagreements on policy or legal issues may be submitted by program staff to the regional attorney.

 

 

4700 Fair Hearings for MCO Decisions

Revision 14-1; Effective March 3, 2014

 

If an applicant wishes a fair hearing with the state of Texas regarding an HCBS STAR+PLUS Waiver (SPW) eligibility denial, he or she must contact the Program Support Unit (PSU) as instructed in the denial notification.

In addition to appealing an adverse action not related to eligibility, the SPW member may also request a fair hearing by contacting PSU.

Section 5000, Automation and Payment Issues in STAR+PLUS

Section 5000, Automation and Payment Issues in STAR+PLUS Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

Revision 21-2; Effective August 1, 2021

 

5100 TxMedCentral

Revision 18-2; Effective September 3, 2018

 

 

 

5110 TxMedCentral Naming Convention and File Maintenance

Revision 21-2; Effective August 1, 2021

 

TxMedCentral is a secure Internet bulletin board that the Texas Health and Human Services Commission (HHSC) and managed care organizations (MCOs) use to share information. TxMedCentral uses specific naming conventions only for documents listed below. HHSC and MCO staff must follow these naming conventions any time one of the following documents is filed in TxMedCentral.

Form H1700-1, Individual Service Plan

The following forms may be used, if appropriate, in development of the individual service plan (ISP). Only Form H1700-1 and Form H1700-2 are uploaded to the MCO's ISP folder in TxMedCentral and should not be uploaded in any other folder:

Two-Digit Plan Identification (ID) Form Number (#) Member ID, Medicaid # or Social Security Number (SSN) Member Last Name (first four letters) Page Number of Form H1700 Sequence Number of Form
## 1700 123456789 ABCD 1 2

This file would be named ##_1700_123456789_ABCD_1_2.doc.

Form H1700-1 and Form H1700-3, completed for non-members, age-outs, and nursing facility (NF) residents transitioning to the STAR+PLUS Home and Community Based Services (HCBS) program, continues to be uploaded to TxMedCentral.

Form H1700-1, completed for members in the community, is submitted to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

Form H3676, Managed Care Pre-Enrollment Assessment Authorization

This form is uploaded to the SPW folder and should not be uploaded in any other folder. An "A" or "B" is added to the sequence number to indicate whether Program Support Unit (PSU) or MCO staff uploaded the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 3676 123456789 ABCD A or B 2

This file would be named ##_3676_123456789_ABCD_A_2.doc if uploaded by PSU staff.

This file would be named ##_3676_123456789_ABCD_B_2.doc if uploaded by the MCO.

Form H2065-D, Notification of Managed Care Program Services

Form H2065-D is uploaded to the SPW folder and should not be uploaded in any other folder.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2065 123456789 ABCD D 2D or 2A
  • Denials will be coded with a “D” (denial) immediately following the form’s sequence number. This denial file would be named ##_2065_123456789_ABCD_D_2D.doc.
  • Approvals will be coded with an “A” immediately following the sequence number. This approval file would be named ##_2065_123456789_ABCD_D_2A.doc.

If a member has an ISP which is electronically generated, Form H2065-D is available in the "LETTERS" tab of the TMHP LTC Online Portal when the member's ISP is selected. Form H2065-D is uploaded to TxMedCentral only for individuals without electronic ISPs.

MCOs must check the TMHP LTC Online Portal to check for updates and notifications electronically generated by Program Support Unit (PSU) staff.

Form H2067-MC, Managed Care Programs Communication

This form is uploaded to the SPW folder and should not be uploaded in any other folder. An "M" or "S" is added to the sequence number to indicate whether the MCO or PSU staff uploaded the form.

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD 2M or 2S

This file would be named ##_2067_123456789_ABCD_2M.doc if uploaded by the MCO.

This file would be named ##_2067_123456789_ABCD_2S.doc if uploaded by PSU staff.

Additional to the standardized naming convention for Form H2067-MC, a separate naming convention has been developed to address use of Form H2067-MC for NF residents who request transition to the community under the STAR+PLUS Home and Community Based Services (HCBS) program. These individuals are considered expedited cases for application to the STAR+PLUS HCBS program. Both the MCO and PSU staff must be able to readily identify communications specific to these cases.

An "M" or "S" continues to be added to the sequence number to denote, respectively, whether the MCO or PSU staff have uploaded the form. The new naming convention for uploading Form H2067-MC, on both member and non-member cases in an NF, is expanded as follows:

Two-Digit Plan ID Form # Member ID, Medicaid # or SSN Member Last Name (first four letters) Section Number Sequence Number of Form
## 2067 123456789 ABCD 1M or 1S MFP

Form H2067-MC file uploaded by the MCO would be named ##_2067_123456789_ABCD_1M_MFP.doc if uploaded by the MCO.

Form H2067-MC file uploaded by the MCO would be named ##_2067_123456789_ABCD_1S_MFP.doc if uploaded by PSU staff.

TxMedCentral Folders

The STAR+PLUS MCOs use the following folders for all STAR+PLUS HCBS program related uploads. Each MCO has two folders with three-letter identifiers:

  • ISP — Individual Service Plan, which contains Form H1700-1 and Form H1700-2; and
  • SPW — STAR+PLUS HCBS program, which contains:
    • Form H2065-D, Notification of Managed Care Program Services;
    • Form H3676, Managed Care Pre-Enrollment Assessment Authorization; and
    • Form H2067-MC, Managed Care Programs Communication.
Primary Folder: MCO Three-Letter Identifiers Secondary Folder: TxMedCentral Folders by Plan
AMC — Amerigroup MCO AMCISP AMCSPW
EVR — United Healthcare Community Plan MCO EVRISP EVRSPW
MOL — Molina MCO MOLISP MOLSPW
SUP — Superior MCO SUPISP SUPSPW
BRV — Cigna-HealthSpring MCO BRVISP BRVSPW

 

5120 Identifying Managed Care Members in the Texas Integrated Eligibility Redesign System

Revision 19-1; Effective June 3, 2019

 

The Individual-Summary screen in the Texas Integrated Eligibility Redesign System (TIERS) contains a managed care segment for any individual who is currently or has been enrolled in managed care. From the Individual-Search screen, enter the individual's information and select Search. The results of the search will appear in Search Results field. Select the individual’s name on the hyperlink. The Individual - Summary screen will appear. Hover over the Individual # field and select Managed Care. The individual's managed care information will appear.

Specific managed care information is located under Individual Managed Care History field. The data elements across the bottom of the screen are: Provider – Plan – Program – County – Begin Date – End Date – Status – Eligibility – Candidature.

These fields contain the following information:

Provider — Contains the name of the provider contracted by the managed care organization (MCO) to deliver services to members.

Plan — Contains the name of the MCO providing Medicaid services to the member.

Program — For managed care members, "STARPLUS" will appear in this field.

County — Individual's county of residence.

Begin Date — Date enrollment began under this plan.

End Date — Date enrollment ended under this plan.

Status — Describes the type of action.

Eligibility — Choices are "candidate" (applicant), "enrolled" (active) and "suspended" (closed).

Candidature — Describes the individual's status.

STAR+PLUS Plan Codes

Service Area Plan Name Plan Codes Plan Codes Dates
Bexar Amerigroup 45 Sept 1, 2011
Molina 46 Sept 1, 2011
Superior 47 Sept 1, 2011
Dallas Molina 9F March 1, 2012
Superior 9H March 1, 2012
El Paso Amerigroup 34 March 1, 2012
Molina 33 March 1, 2012
Harris Amerigroup 7P Sept 1, 2011
United Healthcare 7R Sept 1, 2011
Molina 7S Sept 1, 2011
Hidalgo Cigna-HealthSpring H7 March 1, 2012
Molina H6 March 1, 2012
Superior H5 March 1, 2012
Jefferson Amerigroup 8R Sept 1, 2011
United Healthcare 8S Sept 1, 2011
Molina 8T Sept 1, 2011
Lubbock Amerigroup 5A March 1, 2012
Superior 5B March 1, 2012
Medicaid Rural Service Area (RSA) West Texas Amerigroup W5 Sept 1, 2014
Superior W6 Sept 1, 2014
Medicaid RSA Northeast Texas Cigna-HealthSpring N3 Sept 1, 2014
United Healthcare N4 Sept 1, 2014
Medicaid RSA Central Texas Superior C4 Sept 1, 2014
United Healthcare C5 Sept 1, 2014
Nueces United Healthcare 85 Sept 1, 2011
Superior 86 Sept 1, 2011
Tarrant Amerigroup 69 Sept 1, 2011
Cigna-HealthSpring 6C Sept 1, 2011
Travis Amerigroup 19 Sept 1, 2011
United Healthcare 18 Sept 1, 2011

 

5121 Medicare-Medicaid Plan (MMP) Codes

Revision 19-1; Effective June 3, 2019

 

Service Area Plan Name Plan Codes Plan Codes Dates
Bexar Amerigroup 4F 9/1/15
Molina 4G 9/1/15
Superior 4H 9/1/15
Dallas Molina 9J 9/1/15
Superior 9K 9/1/15
El Paso Amerigroup 3G 9/1/15
Molina 3H 9/1/15
Harris Amerigroup 7Z 9/1/15
United Healthcare 7Q 9/1/15
Molina 7V 9/1/15
Hidalgo Cigna-HealthSpring H8 9/1/15
Molina H9 9/1/15
Superior HA 9/1/15
Tarrant Amerigroup 6F 9/1/15
Cigna-HealthSpring 6G 9/1/15

 

5200 Service Authorization System

Revision 18-2; Effective September 3, 2018

 

 

 

5210 Managed Care Data in the Service Authorization System

Revision 19-1; Effective June 3, 2019

 

The STAR+PLUS Home and Community Based Services (HCBS) program is authorized by the managed care organization (MCO) and registered by Program Support Unit (PSU) staff in the Service Authorization System Online (SASO) with a Service Group (SG) 19 and a service code (SC). If the member's individual service plan (ISP) is electronic, the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal registers the appropriate SG/SC combination, which is verified by PSU staff. Service codes are based on the following:

  • Service Code 12: Use this service code when registering initial service authorizations or annual re-determination service authorizations received up to 90 days prior to the end date of the current ISP.
  • Service Code 13: Use this service code if an ISP is received after the end date of the most recent ISP. Register one service authorization using Service Code 13 effective the day after the end date of the most recent ISP and with an end date that is the end of the month in which the new ISP was received. Register a second service authorization using Service Code 12 with an effective date one day after the Service Code 13 service authorization ends and an end date of one year minus a day from the effective date of the ISP.

Example: A reassessment ISP is received on June 5, 2017, for an ISP that ended May 31, 2017. To register this reassessment, register one service authorization record using "Service Code 13 — Nursing" with a begin date of June 1, 2017, and an end date of June 30, 2017. Then, register a second service authorization record using "Service Code 12 — Case Management" with a begin date of July 1, 2017, and an end date of May 31, 2018.

Example of automatic registration: A reassessment ISP is submitted to the TMHP LTC Online Portal on June 5, 2017, for an ISP that ended May 31, 2017. One service authorization record with "Service Code 13 — Nursing" will be system generated with a begin date of June 1, 2017, and an end date of June 30, 2017. A second service authorization record with "Service Code 12 — Case Management" will be system-generated with a begin date of July 1, 2017, and an end date of May 31, 2018.

 

5220 Money Follows the Person Demonstration Entitlement Tracking and Service Authorization System Online Data Entry

Revision 20-1; Effective March 16, 2020

 

Time spent in a nursing facility (NF) does not count toward the 365-day period; therefore, tracking is required to ensure Money Follows the Person Demonstration (MFPD) individuals receive the full 365-day entitlement period. The entitlement period begins the date the individual who agrees to participate in the demonstration is enrolled in the STAR+PLUS Home and Community Based Services (HCBS) program. The managed care organization (MCO) uploads Form H2067, Managed Care Programs Communication, to TxMedCentral in the MCO folder, indicating the total number of days the member spent in the NF. This information is sent after the 365th day. See Section 3520, Money Follows the Person Demonstration.

The tables below are intended to assist Program Support Unit (PSU) staff in making accurate entries in the Service Authorization System Online (SASO).

Example 1 — No institutionalization during the 365-day period.

Begin Date End Date Service Group Service Code Comments Fund Code
02-13-19 06-15-19 1 1 Individual is discharged from the nursing facility (NF). The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-19 06-01-19 19 12 One-day registration to set the managed care organization (MCO) capitation payment. SASO record entered by PSU staff. Blank
06-15-19 06-14-20 19 12 PSU staff enters SASO record and enters fund code as 19MFP for the entire period. 19MFP
06-15-20 06-30-20 19 12 PSU staff enters the remaining individual service plan (ISP) period without the 19MFP fund code. Blank

 

Example 2 — Institutionalization during the 365-day period.

Begin Date End Date Service Group Service Code Comments Fund Code
02-13-19 06-15-20 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-20 06-01-20 19 12 One-day registration to set the MCO capitation payment. SASO record entered by PSU staff. Blank
06-15-20 06-14-21 19 12 PSU staff enters SASO record and enters fund code as 19MFP for the entire period. 19MFP
06-15-21 06-30-21 19 12 PSU staff enters the remaining ISP period without the 19MFP fund code. Blank
The MCO has notified PSU staff this member spent a total of 15 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:
06-15-21 06-29-21 19 12 PSU staff enters the MFPD period for the 15 days the individual was in the hospital. 19MFP
06-30-21 06-30-21 19 12 MFPD period reached the 365th day on 06-29-21. ISP had one day remaining. Blank

 

Example 3 — Institutionalization during the 365-day period.

Begin Date End Date Service Group Service Code Comments Fund Code
02-13-19 06-15-20 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-20 06-01-20 19 12 One-day registration to set the MCO capitation payment. SASO record entered by PSU staff. Blank
06-15-20 06-14-21 19 12 PSU staff enters SASO record and enters fund code as 19MFP for the entire period. 19MFP
06-15-21 06-30-21 19 12 PSU staff enters the remaining ISP period without the 19MFP fund code. Blank
07-01-21 06-30-22 19 12 PSU staff enters reassessment ISP. Blank
The MCO has notified PSU staff this member spent a total of 25 days in the hospital during the MFPD period. PSU staff must correct SASO as follows:
06-15-21 06-30-21 19 12 PSU staff enters the MFPD period for the 16 of the 25 days the individual was in the hospital. 19MFP
07-01-21 07-09-21 19 12 PSU staff enters the MFPD period for the last nine days of the 25-day period in which the individual was in the hospital. 19MFP
07-10-21 06-30-22 19 12 PSU staff enters the remainder of the reassessment ISP period. Blank

 

Example 4 — Institutionalization in NF during MFPD period.

Note: The difference between Example 2 and Example 4 is that for NF stays, the PSU staff has to correct STAR+PLUS HCBS program or NF overlaps.

Begin Date End Date Service Group Service Code Comments Fund Code
02-13-19 06-15-20 1 1 Individual is discharged from the NF. The NF begin and end dates are derived from forms submitted by NFs. Blank
06-01-20 06-01-20 19 12 One-day registration to set the MCO capitation payment. SASO record entered by PSU staff. Blank
06-15-20 06-14-21 19 12 PSU staff enters SASO record and enters fund code as 19MFP for the entire period. 19MFP
06-15-21 06-30-21 19 12 PSU staff enters the remaining ISP period without the 19MFP fund code. Blank
08-15-20 08-29-20 1 1 The NF begin and end dates are derived from forms submitted by NFs. Blank
The PSU staff becomes aware this individual spent a total of 15 days in the NF during the MFPD period. PSU staff must correct SASO as follows:
06-15-20 08-14-20 19 12 PSU staff must correct STAR+PLUS HCBS program or NF overlap. 19MFP
08-30-20 06-29-21 19 12 PSU staff enters the MFPD period, including the 15 days the member was in the NF. 19MFP
06-30-21 06-30-21 19 12 MFPD period reached the 365th day on 06-29-21. ISP had one day remaining. Blank

 

5300 Texas Medicaid & Healthcare Partnership Long Term Care Online Portal

Revision 19-1; Effective June 3, 2019

 

 

 

5310 Using the TMHP Long Term Care Online Portal

Revision 21-2; Effective August 1, 2021

 

The managed care organization (MCO) must submit the Medical Necessity and Level of Care (MN/LOC) Assessment through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal to process a determination of MN and associated resource utilization group (RUG) value. MCOs submit the MN/LOC Assessment as an:

  • Initial assessment, submitted when an applicant or individual is being assessed for the STAR+PLUS Home and Community Based Services (HCBS) program or eligibility for Community First Choice (CFC) services.
  • Annual assessment.
  • Significant change in status assessment for members only receiving CFC as an upgrade for HCBS.

The MCO has the ability to correct or inactivate assessments submitted within specific time frames. Corrections are completed when certain data elements require correction (refer to the TMHP Community Waiver User Guide to determine which fields are correctable). Inactivations are completed when a correction is needed after the 14-day correction time frame allowable time to submit corrections has passed and when the field(s) requiring correction are not correctable and to remove the assessment from the TMHP LTC Online Portal.

The MCO has access to the TMHP LTC Online Portal to:

  • check and verify MN status and RUG;
  • review workflow actions that result from the submittal of the MN/LOC Assessment or the Individual Service Plan (ISP);
  • manage and take action in response to workflow messages; and
  • submit Form H1700-1, Individual Service Plan, for initial, change, and reassessment of members with the exception of age-outs and nursing facility (NF) residents transitioning to the STAR+PLUS HCBS program.

More information about submitting Form H1700-1 through the TMHP LTC Online Portal is available in Appendix XXVI, Long Term Care Online Portal User Guide for Managed Care Organizations.

Submittal of the MN/LOC Assessment through the TMHP LTC Online Portal creates MN, Level of Service (LOS) and Diagnosis (DIA) records in the Service Authorization System Online (SASO). The RUG value is located in the LOS record.

Status messages appear in the TMHP LTC Online Portal workflow folder when an MN/LOC Assessment is submitted. Additionally, error messages with status codes appear when TMHP processing cannot be completed. Status messages may be generated when:

  • assessments have missing information;
  • the system cannot match the assessment to an applicant or individual record;
  • the individual is enrolled in another 1915c Medicaid waiver program;
  • assessment forms are out of sequence;
  • corrections are made to assessments after SASO records have been generated based on the assessment;
  • changes occur in MN or LOS status that affect applicant or individual services; or
  • previous SASO records were manually changed within the current individual service plan (ISP) period.

This list is not all inclusive.

Messages will appear in the workflow folder to indicate whether or not the TMHP LTC Online Portal action was processed as complete. In some situations, MN, LOS and DIA records will not be generated to SASO; in other situations, SASO records will be generated but messages may still appear in the workflow for required action.

PSU staff:

  • may update SASO records and/or take specific case actions based on the MN and RUG information found in the TMHP LTC Online Portal;
  • must document responses in the TMHP LTC Online Portal to workflow messages appearing for an individual by clicking on applicable buttons related to the messages; and
  • must check TMHP LTC Online Portal workflow items to process case actions.

CMS coordinators need to contact PSU staff to update SASO records and/or take specific case actions based on the MN and RUG information found in the TMHP LTC Online Portal.

 

5400 Administrative Payment Process

Revision 19-1; Effective June 3, 2019

 

When an individual is aging out of the Texas Health Steps Comprehensive Care Program (THSteps-CCP), Medically Dependent Children Program (MDCP) or has been approved for a nursing facility (NF) diversion slot, the managed care organization (MCO) must authorize services to start on the day of eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program, which may not be the first of the month. If the eligibility date is not the first of the month, the MCO must follow the administrative payment process for STAR+PLUS services provided between the eligibility date and the managed care enrollment date, as applicable. The administrative payment process must be used for the Texas Health and Human Services Commission (HHSC) to issue payment to the MCO and for the MCO to pay the provider.

Once the MCO authorizes services, the provider:

  • prepares Form 1500, Health Insurance Claim; and
  • submits the form to the MCO within the 95-day filing deadline.

Within five business days of receiving Form 1500, the MCO verifies the provider was authorized to deliver the services billed on Form 1500, the information on Form 1500 meets the clean claim requirements as defined in the Uniform Managed Care Manual, Chapter 2.0, and the claim met the 95-day filing deadline. Once the MCO verifies this information, the MCO:

  • sends Form 1500 by secure email to Program Support Unit (PSU) staff if the provider:
    • is authorized to deliver the service;
    • met the clean claim requirements; and
    • submitted the claim to the MCO within the 95-day filing deadline; or
  • denies payment via the MCO denial process if the provider:
    • is not authorized to deliver the services;
    • did not meet the clean claim requirements; or
    • did not meet the 95-day filing deadline.

Within two business days of receiving Form 1500, PSU staff follow the requirements in this handbook section.

If the decision is to approve the administrative payment, the following also occurs:

  • Contract Compliance and Support (CCS) sends the approved payment voucher to the State Comptroller for processing and payment to the MCO; and
  • the MCO pays the provider within one week of receipt of payment from the State Comptroller.

If the decision is to deny the administrative payment, ERS staff email the PSU staff who emailed the request that the administrative payment has been denied and the reason for the denial.

Within two business days of receipt of email from the ERS, the PSU staff who submitted the request for administrative payment notify the MCO of the approval or denial decision by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral.

Section 6000, Specific STAR+PLUS HCBS Program Services

Section 6000, Specific STAR+PLUS HCBS Program Services Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

Revision 21-2; Effective August 1, 2021

 

6100 Home and Community Based Services

Revision 18-2; Effective September 3, 2018

 

 

 

6110 Program Overview

Revision 18-2; Effective September 3, 2018

 

 

 

6111 Service Introduction

Revision 19-1; Effective June 3, 2019

 

The service array under the STAR+PLUS Home and Community Based Services (HCBS) program is designed to offer home and community-based services as cost-effective alternatives to institutional care in Medicaid certified nursing facilities. Eligible members receive services according to their specific needs, as defined by an assessment process, based on informed choice and through a person-centered process.

Agencies contracted with managed care organizations (MCOs) provide services to members living in their own homes, foster homes, assisted living facilities (ALFs) and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the MCOs, as identified in Section 6113, General Requirements for MCOs, and in accordance with the ISP.

 

6112 Service Locations for STAR+PLUS HCBS Program

Revision 19-1; Effective June 3, 2019

 

All services through the STAR+PLUS Home and Community Based Services (HCBS) program, except minor home modifications (MHMs), can be provided to members in locations of their choice. Nursing services, therapy services, adaptive aids (including dental) and medical supplies may be provided to a STAR+PLUS HCBS program member residing in an assisted living facility (ALF) contracted to provide STAR+PLUS HCBS program services. Per Title 42 of the Code of Federal Regulations (CFR), Subpart K, Section 441.530(a)(2), the following locations are excluded from STAR+PLUS HCBS program service locations, with the exception of out-of-home respite care:

  • Nursing facilities (NFs);
  • Psychiatric hospitals;
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID);
  • Hospitals providing long term care; and
  • Locations that have the qualities of an institution.

 

6113 General Requirements for MCOs

Revision 21-2; Effective August 1, 2021

 

The managed care organization (MCO) must coordinate and ensure delivery and initiation of the array of services in accordance with Form H1700-1, Individual Service Plan. Services include:

  • personal assistance services (PAS);
  • nursing services;
  • physical therapy (PT);
  • occupational therapy (OT);
  • speech therapy (ST) services;
  • cognitive rehabilitation therapy (CRT);
  • adaptive aids;
  • medical supplies;
  • minor home modifications (MHMs);
  • emergency response services (ERS);
  • assisted living (AL);
  • adult foster care (AFC);
  • home-delivered meals;
  • dental services;
  • transition assistance services (TAS);
  • respite care;
  • employment assistance; and
  • supported employment.

The MCO must identify, coordinate and when applicable, authorize available value added services, Medicare and other third-party resources (TPRs) before authorizing those services on the member's individual service plan (ISP). Refer to specific service descriptions for exceptions or limitations.

 

6114 Service Plan

Revision 21-2; Effective August 1, 2021

 

The managed care organization (MCO) must authorize all services identified on the individual service plan (ISP). When sending an authorization to a provider, the MCO may send the following:

  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-3, Individual Service Plan – Signature Page;
  • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum,
  • Form H6516, Community First Choice Assessment; or
  • Other forms and assessments, as applicable.

The MCO must send any functional assessment documentation to the provider when requested. The MCO will upload the signed Form H1700-3 to the XXXISP folder in TxMedCentral using the appropriate naming convention. If Form H1700-1 is electronic, the MCO will submit Form H1700-1 through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal or TMHP Electronic Data Interchange. All other forms are maintained in the member's file folder.

The MCO registered nurse (RN) service coordinator or MCO contracted RN service coordinator and the member or authorized representative (AR) must sign Form H1700-3 prior to the start date of the ISP to certify the proposed ISP accurately reflects the needs of the member.

Verbal authorizations are permitted for ISP changes, as long as the name of the person who gave the verbal authorization and the date the verbal authorization was given, are included on the signature line. The proposed ISP should be presented to the member following development of the proposed ISP and the member should sign Form H1700-3 to indicate acceptance.

 

6115 Individual Agreement for Services

Revision 18-2; Effective September 3, 2018

 

Managed care organizations (MCOs) may choose to provide services through other pay arrangements with individuals awaiting determination of STAR+PLUS Home and Community Based Services (HCBS) program eligibility. MCOs will not be reimbursed for services delivered prior to the determination of STAR+PLUS HCBS program eligibility.

The provider cannot be held responsible for deficits or failure in areas not included in the provider’s portion of the member's individual service plan (ISP) when gratuitous care or care by other resources is being provided.

 

6116 Refusal to Serve Members

Revision 18-2; Effective September 3, 2018

 

If a provider refuses to serve a member, the reason the provider cannot adequately meet the needs of the member must be stated in writing to the member’s managed care organization (MCO). The reason for provider refusal must be related to the provider’s limitation and not previous experience with the member or discriminated against because of age, disability or gender, etc. The provider must work with the MCO to coordinate alternative provider agency arrangements. The MCO must coordinate the transfer of services on behalf of the member.

 

6117 Service Planning

Revision 21-2; Effective August 1, 2021

 

Services and care provided, as identified and authorized on Form H1700-1, Individual Service Plan, must assist the member to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Services provided are tailored to meet the member's goals and needs based upon her or his medical condition, mental and functional limitations, ability to self-manage, and availability of family and other support.

The managed care organization (MCO) must assure the member's informed choice and convenience are incorporated into the planning and provision of the member's care by involved professionals. The service planning process must be person-centered and the individual service plan (ISP) must reflect the member’s goals, needs, strengths and preferences with regard to the manner of delivery of STAR+PLUS Home and Community Based Services (HCBS) program services. Members must be encouraged and allowed to play an active role in determining their ongoing plan of care (POC).

MCOs must recognize and support the member's right to a dignified existence, privacy and self-determination.

 

6118 Personal Assistance Services

Revision 21-2; Effective August 1, 2021

 

Personal assistance services (PAS) provide assistance to members in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the member’s needs. Most members will receive PAS through Community First Choice (CFC), with the exception of members who are medical assistance only (MAO), or members who also require protective supervision. Protective supervision is not a benefit of CFC.

PAS includes assistance with the performance of ADLs and IADLs necessary to maintain the home as a clean, sanitary and safe environment. PAS is provided to the member, as authorized on Form H1700-1, Individual Service Plan, or as delivered through CFC. 

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service. Federal and state rules prohibit a spouse from being a paid PAS provider.

 

6118.1 Description of Personal Assistance Services

Revision 19-1; Effective June 3, 2019

 

  • Personal assistance services (PAS) include, but are not limited to, the following:
    • assisting with basic self-care tasks known as activities of daily living (ADLs). These include, but are not limited to, self-feeding, dressing, bathing, personal hygiene and grooming, transferring, and going to the toilet;
    • assisting with instrumental activities of daily living (IADLs). These are activities that allow an individual to live independently in the community. These include, but are not limited to, cleaning and maintaining the house, preparing meals, shopping for groceries, and taking prescribed medications;
    • providing extension of therapy services;
    • providing assistance with ambulation and balance;
    • assisting with medications that are normally self-administered;
    • performing health maintenance activities, as defined by the Texas Board of Nursing;
    • performing nursing tasks delegated and supervised by a registered nurse (RN), in accordance with the Texas Board of Nursing rules;
    • escorting the member on trips to obtain medical diagnosis, treatment or both; and
    • providing protective supervision.
  • The managed care organization (MCO) must authorize and ensure the provision of PAS as identified on Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060; and Form H2060-B, Needs Assessment Addendum, and authorize PAS, as applicable, to members living in their own homes or other community settings.
  • Activities purchased under PAS are limited to the member’s personal space and solely for the member’s personal needs. The following examples of services not reimbursable under the STAR+PLUS Home and Community Based Services (HCBS) program are:
    • taking care of household non-service related pets;
    • ironing;
    • moving furniture;
    • cleaning windows; and
    • performing yard work other than yard hazard removal.

Shopping

Shopping is intended for the purchase of groceries, medications, or other items that support the health, safety, and well-being of a member. This may be done by the attendant on behalf of the individual or the attendant may accompany the individual to assist with this task. Neither the provider nor the attendant can charge the member for transportation costs incurred in the performance of this task.

Ambulation

Ambulation is a personal care task that involves non-skilled assistance with walking or transferring while taking the usual precautions for safety (that is, standby assistance, gentle support of an elbow for balance or assuring balance of a walker). This does not involve nursing intervention. No special precautions are needed other than for safety measures.

To facilitate safe member ambulation or movement, the attendant may need to ensure safe pathways throughout the home for the member. Examples include those who use wheelchairs, walkers or crutches, or for members with visual impairment. The attendant care provider or member (or authorized representative (AR)) addresses this activity during orientation and on an ongoing basis for an attendant who provides services to a member needing assistance.

The member’s primary care provider (PCP) may request specific ambulation orders. If ambulation is authorized as a nursing task, the service coordinator must not authorize ambulation as a non-skilled task on Form H2060, Form H6516 and any addendums to Form H2060. Authorizing ambulation as a nursing task and at the same time as a non-skilled task is a duplication of services. When completing the functional assessment on Form H2060 and any addendums to Form H2060, the service coordinator must consider the member's need for ambulation. If it appears the member needs both skilled and non-skilled ambulation assistance, the service coordinator must document in the case record why and how the member requires both. The service coordinator can approve both if there is no duplication.

Escort

Escorting is for healthcare-related appointments and does not include the direct transportation of the member, or the receipt or exchange of health information by the attendant. Escort services may be provided for safety needs, to enter or exit a building, or to remain safe during wait time while attending medical appointments. Transportation for Medicaid members to Medicaid appointments is available in every county through the Medical Transportation Program (MTP). Transportation is not included as an activity in the escort task.

Protective Supervision

The purpose of protective supervision is to assure the health and welfare of a member with a cognitive impairment, memory impairment or physical weakness. Protective supervision is authorized by the MCO, and assures supervision of the member during instances in which the member’s informal support is unavailable.

Protective supervision is supervision only and does not include the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the member from injury due to her or his cognitive/memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn herself or himself, or try to walk and then fall. Protective supervision is not routinely authorized for members who can safely live on their own, nor is it intended to provide 24-hour care. Protective supervision is not a benefit of CFC and can be on a member’s individual service plan (ISP), even if the member receives CFC.

Exercise

A member may request, or a physician may order, assistance with walking as a form of exercise. A member must be ambulatory for exercise to be an authorized PAS activity.

Therapy Extension

Licensed therapists may choose to instruct the PAS attendant on the proper way to assist the member in follow-up of therapy sessions. This assistance or support provides reinforcement of instruction and aids in the rehabilitative process. Therapy extension is documented on Form H2060-A.

 

6118.2 Personal Assistance Services Attendants

Revision 19-1; Effective June 3, 2019

 

Personal assistance services (PAS) are performed by personal care attendants who:

  • are not themselves recipients of PAS;
  • are employed by a managed care organization (MCO) contracted provider or employed by the member or the employer of record under the Consumer Directed Services (CDS) Option;
  • are not the spouses of members;
  • perform all of the services available within their scope of competency;
  • may serve as backup attendants to initiate services, prevent a break in service and provide ongoing service; 
  • are required to provide services that meet a member’s health and safety needs; and
  • if applicable, meet additional eligibility requirements under the CDS option.

 

6200 Nursing Services

Revision 18-2; Effective September 3, 2018

 

Nursing services are services that are within the scope of the Texas Nursing Practice Act and are provided by a registered nurse (RN) (or licensed vocational nurse (LVN) under the supervision of an RN) licensed to practice in the state. In the Texas state plan, nursing services are provided only for acute conditions or exacerbations of chronic conditions lasting less than 60 days. Nursing services provided in the STAR+PLUS Home and Community Based Services (HCBS) program cover nursing tasks associated with ongoing chronic conditions such as medication administration and supervising delegated tasks. This broadens the scope of these services beyond extended state plan services. Extended state plan services are services provided which exceed benefits allowed under the state plan.

Nursing services purchased through the STAR+PLUS HCBS program can be skilled or specialized in nature and do not replace a member's acute care benefit. Nursing services are assessment, planning and interventions provided by a person licensed to engage in professional nursing or vocational nursing in Texas, or licensed in a state that has adopted the Nurse Licensure Compact. Proof of valid licensure can be verified by viewing the nurse's license at the Texas Board of Nursing website at https://www.bon.texas.gov/.

To assure quality of care for members in the STAR+PLUS HCBS program, the managed care organization (MCO) is responsible for coordinating services following a significant change in the member's condition. The MCO may become aware of a significant change in condition through interaction with members, family or an authorized representative (AR), and by performing interim assessments on current STAR+PLUS HCBS program members. The MCO is responsible for initiating appropriate services and supports to meet the care and well-being of the member interventions on a timely basis.

 

6210 Settings

Revision 18-2; Effective September 3, 2018

 

Nursing services can be delivered in a member's own home or family home, in a personal care facility, assisted living facility (ALF) or an adult foster care (AFC) setting. Nursing services purchased through the STAR+PLUS Home and Community Based Services (HCBS) program may not be provided in the following settings as defined in 42 Code of Federal Regulations (CFR), §441.530(a)(2):

  • Nursing facilities (NFs);
  • Psychiatric hospitals;
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID);
  • Hospitals providing long term care; and
  • Locations that have the qualities of an institution.

 

6220 Nursing Services to Meet Member Needs

Revision 21-2; Effective August 1, 2021

 

All STAR+PLUS Home and Community Based Services (HCBS) program members meet medical necessity (MN) and have a need for one or more nursing tasks, as described in the Texas Administrative Code (TAC), Title 40, §19.2401. It is the responsibility of the managed care organization (MCO) service coordinator to identify and document in the individual service plan (ISP) or Form H1700-2, Individual Service Plan – Addendum, how the member's nursing need(s) will be met.

The member's nursing needs may be met by direct or delegated nursing, health maintenance activity (HMA), informal support, or a combination, as described below:

  • Direct nursing provided by a registered nurse (RN) or a licensed vocation nurse (LVN). This includes nursing services with a third-party resource (TPR) as the payer and nursing with the STAR+PLUS HCBS program as the payer.
  • Delegation by an RN to an unlicensed assistive person (UAP), such as a personal attendant in accordance with Texas Board of Nursing rules, which may be delivered through Community First Choice (CFC) or the STAR+PLUS HCBS program.
  • RN determination that a nursing task(s) is an HMA in accordance with Texas Board of Nursing rules. HMAs include performance of nursing tasks by a paid attendant and by informal support. For a member who chooses the provider or service responsibility option (SRO), the MCO service coordinator, in conjunction with the agency RN, makes the determination that a nursing task is an HMA.
  • Informal support, such as unpaid family members, may be trained in the provision of nursing tasks to meet a member's needs. The MCO service coordinator must identify and document the tasks to be performed by the informal support on Form H1700-2, and the informal support must agree to perform the nursing tasks.

For information about delegation and HMAs, refer to the TAC for Texas Board of Nursing, Title 22, Part 11, Chapters 224 and 225.

 

6230 Nursing Services in Assisted Living Facilities

Revision 20-1; Effective March 16, 2020

 

Assisted living facilities (ALFs) must have sufficient staff to assist with member medication regimens (Texas Administrative Code (TAC), Title 26, §553.41). Nursing for this task may be included on the individual service plan (ISP), depending on the member’s needs and the facility type. Licensed nurses who own an ALF or are employed by the facility may directly administer medication to members residing in ALFs, but are not required to do so. In ALFs, delegation of nursing tasks to facility attendants is not allowed by licensure. See Section 7200, Assisted Living Services, Section 7224, Personal Care 3, and Section 7230, Other Services Available to Members.

If, because of licensure, an ALF does not provide nursing services, other facility employees may not deliver services other than personal assistance services (PAS) and administration of medications. If a resident needs additional services that are not available in the ALF, the managed care organization (MCO) must ensure the member’s needs are met. The MCO may do so through contract with a Home and Community Support Services Agency (HCSSA) or an independent health care provider.

PAS provided by the ALF include assistance with feeding, dressing, moving, bathing, or other personal needs or maintenance; or general supervision or oversight of the physical and mental well-being of a person who needs assistance to maintain a private and independent residence in the ALF; or assistance to a member to manage her or his personal life, regardless of whether a guardian has been appointed for the person.

 

6240 Nursing Services in Adult Foster Care Homes

Revision 18-2; Effective September 3, 2018

 

Based upon the assessment performed by the managed care organization (MCO) registered nurse (RN) service coordinator, the RN service coordinator determines a member’s classification level for adult foster care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member. Nursing services may be purchased through the STAR+PLUS Home and Community Based Services (HCBS) program, depending on the member's assessed need and the AFC home classification. See Section 7133 Classification Levels, for additional information.

 

6250 Specialized Nursing

Revision 18-2; Effective September 3, 2018

 

Specialized nursing services delivered by a registered nurse (RN) or licensed vocational nurse (LVN) are available through the STAR+PLUS Home and Community Based Services (HCBS) program. Specialized nursing services may be used when a member requires, as determined by a physician, daily skilled nursing to:

  • cleanse, dress and suction a tracheostomy; or
  • provide assistance with ventilator or respirator care.

 

6300 Therapy Services

Revision 19-1; Effective June 3, 2019

 

Therapy services provided through the STAR+PLUS Home and Community Based Services (HCBS) program are long term services and do not replace a member’s acute care benefit. Therapy services include the evaluation, examination and treatment of physical, functional, cognitive, speech and hearing disorders and/or limitations. Therapy services include the full range of activities under the direction of a licensed therapist within the scope of her or his state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic. If the therapy is provided outside the member's residence based on the member's choice, the member is responsible for providing her or his own transportation or accessing the Medicaid Medical Transportation Program (MTP).

If the therapy is provided outside the member's residence because of the convenience of the provider, the provider is responsible for providing the member's transportation. If a member resides in an adult foster care (AFC) or an assisted living (AL) setting and therapy is provided in an outpatient center or clinic (see Section 6112, Service Locations for STAR+PLUS HCBS Program), the AL provider or AFC provider is responsible for arranging for transport or directly transporting the member.

Occupational therapy (OT), physical therapy (PT), speech therapy (ST) and cognitive rehabilitative therapy services are covered by the STAR+PLUS HCBS program only after the member has exhausted her or his therapy benefit under Medicare, Medicaid or other third-party resources (TPRs). Providers contracted with the managed care organization (MCO) must provide the OT, PT, ST and cognitive rehabilitation therapy (CRT) services as identified on the member's individual service plan (ISP). Individuals providing therapy services must be licensed in Texas in their profession or be licensed or certified as assistants and employed directly or through sub-contract or personal service agreements with a provider or through the Consumer Directed Services (CDS) Option.

PT is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed PT assistant directly supervised by a licensed physical therapist. PT is the evaluation, examination and utilization of exercises, rehabilitative procedures, massage, manipulations and physical agents (such as mechanical devices, heat, cold, air, light, water, electricity and sound) in the aid of diagnosis or treatment.

OT consists of interventions and procedures to promote or enhance safety and performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. It is provided by a licensed occupational therapist or a certified OT assistant directly supervised by a licensed occupational therapist.

ST in the STAR+PLUS HCBS program is defined as evaluation and treatment of impairments, disorders or deficiencies related to an individual's speech and language. The scope of speech, hearing and language therapy services offered to STAR+PLUS HCBS program participants exceeds the state plan as the service in this context is available to adults. It is provided by a speech-language pathologist or a licensed associate in speech-language pathology under the direction of a licensed speech-language pathologist.

 

6310 Initiation of Assessment and Therapy

Revision 18-2; Effective September 3, 2018

 

Upon member request or recommendation from the nurse, primary care provider or service coordinator for a therapy assessment, the managed care organization (MCO) service coordinator must work with the member to select a provider for the assessment. The assessment must be submitted by the provider for the MCO to authorize service hours based on physician orders and medical necessity (MN) review.  Any therapy for the management of a chronic condition must be included on the individual service plan (ISP).

 

6320 Responsibilities of Licensed Therapists in STAR+PLUS HCBS Program

Revision 18-2; Effective September 3, 2018

 

Responsibilities of the licensed therapists include, but are not limited to, the following:

  • assessing the member's need for therapy, adaptive aids and minor home modifications (MHMs);
  • delivering direct therapy as authorized in the individual service plan (ISP);
  • supervising delivery of therapy rendered by the therapy assistant as authorized in the ISP;
  • informing the physician and other team members of changes in the member's health status requiring a service plan change;
  • training the member’s attendant or caregiver to extend therapeutic interventions;
  • training the member to use adaptive aids; and
  • participating in interdisciplinary team meetings, when appropriate and requested by the managed care organization (MCO).

 

6330 Cognitive Rehabilitation Therapy

Revision 18-2; Effective September 3, 2018

 

Cognitive rehabilitation therapy (CRT) is a service that assists a member in learning or relearning cognitive skills lost or altered as a result of damage to brain cells/chemistry in order to enable the member to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary (MN) through an assessment conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the individual service plan (ISP) developed by the assessor, and includes reinforcing, strengthening or re-establishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. Qualified providers include:

  • Psychologists licensed under Texas Occupations Code Chapter 501;
  • Speech and language pathologists licensed under Title 3 of the Texas Occupations Code, Subtitle G, Chapter 401; or
  • Occupational therapists licensed under Title 3 of the Texas Occupations Code, Subtitle H, Chapter 454.

 

6400 Adaptive Aids and Medical Supplies

Revision 19-1; Effective June 3, 2019

 

Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their abilities to perform activities of daily living (ADLs), or to perceive, control or communicate with the environment in which they live. Adaptive aids and medical supplies are reimbursed with STAR+PLUS Home and Community Based Services (HCBS) program funds, when specified in the individual service plan (ISP), with the goal of providing individuals a safe alternative to nursing facility (NF) placement.

This service also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items; and durable and non-durable medical equipment not available under the Texas state plan, such as vehicle modifications, service animals and supplies, environmental adaptations, aids for daily living, reachers, adapted utensils and certain types of lifts.

The annual cost limit of this service is $10,000 per ISP year. The managed care organization (MCO) may exceed the $10,000 cost limit; however, the MCO must not include any costs over the $10,000 on any cost reports, claims, encounters or financial statistical reports. 

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service.

Adaptive aids and medical supplies are limited to the most cost-effective items that:

  • meet the member's needs;
  • directly aid the member to avoid premature NF placement; and
  • provide NF residents an opportunity to return to the community.

 

6410 List of Adaptive Aids and Medical Supplies

Revision 18-2; Effective September 3, 2018

 

Adaptive aids and medical supplies are covered by the STAR+PLUS Home and Community Based Services (HCBS) program only after the member has exhausted state plan benefits and any third-party resources (TPRs), including product warranties or Medicare and Medicaid home health the member is eligible to receive.

If a vehicle modification costs $1,000 or more and the vehicle has been driven more than 75,000 miles or is over four years old, the managed care organization (MCO) contracted provider must:

  • obtain a written evaluation by an experienced mechanic to ensure the sound mechanical condition of all major components of the vehicle;
  • document the experience of the mechanic doing the evaluation; and
  • include the actual cost of the written evaluation as part of the invoice cost not to exceed $150.

Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of but are not limited to following:

  • lifts:
    • wheelchair porch lifts;
    • hydraulic, manual or other electronic lifts;
    • stairway lifts;
    • bathtub seat lifts;
    • ceiling lifts with tracks;
    • transfer bench;
  • mobility aids, including batteries and chargers:
    • manual or electric wheelchairs and necessary accessories;
    • customized wheelchair with documentation of cost effectiveness;
    • three- or four-wheel scooters;
    • mobility bases for customized chairs;
    • braces, crutches, walkers and canes;
    • forearm platform attachments for walkers and motorized/electric wheelchairs;
    • prescribed prosthetic devices;
    • prescribed orthotic devices, orthopedic shoes and other prescribed footwear, including diabetic shoes if the member does not have Medicare and there is a documented medical need and a physician order for the shoes;
    • diabetic slippers or socks;
    • prescribed exercise equipment and therapy aids;
    • portable ramps;
  • respiratory aids:
    • ventilators or respirators;
    • back-up generators;
    • oxygen containers or concentrators, and related supplies;
    • continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines, including headgear;
    • nebulizers;
    • portable air purifiers and filters for a member with chronic respiratory diagnosis such as asthma, Chronic Obstructive Pulmonary Disease (COPD), bronchitis or emphysema;
    • suction pumps;
    • incentive spirometers and peak flow meters;
  • positioning devices:
    • standing boards, frames and customized seating systems;
    • electric or manual hospital beds, tilt frame beds and necessary accessories;
    • hospital beds, including electric controls, manual cranks or other items related to the use of the bed (Medicare/Medicaid can cover hospital beds, specialty mattresses and specialty hospital bed sheets for skin breakdown);
    • replacement mattresses;
    • egg crate mattresses, sheepskin and other medically related padding;
    • wheelchair cushions;
    • elbow, knee and heel protectors and hand rolls for positioning;
    • arm slings, arm braces and wrist splints;
    • abdominal binders;
    • trapeze bars;
  • communication aids (including repair, maintenance and batteries):
    • augmentative communication devices:
      • direct selection communicators;
      • alphanumeric communicators;
      • scanning communicators;
      • encoding communicators;
      • speaker and cordless telephones for persons who cannot use conventional telephones;
    • speech amplifiers, aids and assistive devices;
    • interpreters;
  • control switches or pneumatic switches and devices:
    • sip and puff controls;
    • adaptive switches or devices;
  • environmental control units:
    • locks;
    • electronic devices;
    • voice-activated, light-activated and motion-activated devices;
  • medically necessary (MN) durable medical equipment not covered in the state plan for the Texas Medicaid Program;
  • temporary lease or rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment;
  • payment of premium deductibles and co-insurance (for items covered under the STAR+PLUS HCBS program), including rentals for Medicare or TPRs, if not covered under the Qualified Medicare Beneficiary or the Medicaid Qualified Medicare Beneficiary programs;
  • modifications or additions to primary transportation vehicles:
    • van lifts;
    • driving controls:
      • brake or accelerator hand controls;
      • dimmer relays or switches;
      • horn buttons;
      • wrist supports;
      • hand extensions;
      • left-foot gas pedals;
      • right turn levers;
      • gear shift levers;
      • steering spinners;
    • MN air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate temperature;
    • removal or placement of seats to accommodate a wheelchair;
    • installation, adjustments or placement of mirrors to overcome visual obstruction of wheelchair in vehicle;
    • raising the roof of the vehicle, lowering the floor or modifying the suspension of the vehicle to accommodate an individual riding in a wheelchair;
    • installation of frames, carriers, lifts for transporting mobility aids;
    • installation of trailer hitches for trailers used to transport wheelchairs or scooters;

    Note: If the adaptive aid is a vehicle modification, the program provider must obtain written approval from the vehicle’s owner before making the modification. The owner must sign and date the approval. The MCO must maintain documentation that the contracted provider ensured the specifications for a vehicle modification included information on the vehicle to be modified, including:

    • the year and model of the vehicle;
    • a determination that the vehicle is the member's primary vehicle;
    • proof of ownership of the vehicle;
    • current state inspection and registration for the vehicle;
    • any required state insurance for the vehicle;
    • mileage of the vehicle;
    • an itemized list of parts and accessories, including prices;
    • an itemized list of required labor, including labor charges; and
    • warranty coverage.
  • sensory adaptations:
    • corrective lenses including eyeglasses not covered by the state plan;
    • hearing aids not covered by the state plan;
    • auditory adaptations to mobility devices; and
  • adaptive equipment for activities of daily living (ADLs):
    • assistive devices:
      • reachers;
      • stabilizing devices;
      • weighted equipment;
      • holders;
      • feeding devices, including:
      • electric self-feeders;
      • food processors and blenders – only for members with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances;
    • variations of everyday utensils:
      • shaped, bent, built-up utensils;
      • long-handled equipment;
      • addition of friction covering;
      • coated feeding equipment;
    • medication reminder systems, including those for the visually disabled;
    • walking belts and physical fitness aids;
    • specially adapted kitchen appliances;
    • toilet seat reducer rings unless member resides in an assisted living facility (ALF);
    • bedside commodes;
    • hand-held shower sprays unless member resides in an ALF;
    • shower chairs unless member resides in ALF/residential care facility;
    • electric razors;
    • electric toothbrushes;
    • water picks;
    • service animals and maintenance including veterinary expenses;
    • over-bed tray tables unless member resides in an ALF;
    • safety devices, such as:
      • safety padding;
      • helmets;
      • elbow and knee pads;
      • visual alert systems;
    • medically necessary heating and cooling equipment for members with respiratory or cardiac problems, people who cannot regulate temperature or people who have conditions affected by temperature;
    • one window or portable air conditioner, including wiring, for a member’s main living area, such as a bedroom;
    • medical supplies necessary for therapeutic or diagnostic benefits for:
      • tracheostomy care;
      • decubitus care;
      • ostomy care;
      • pulmonary, respirator/ventilator care; and
      • catheterization.

Other types of supplies include:

  • incontinence supplies, including diapers, disposable or washable bed pads, briefs, protective liners, pull ups, wipes, moisture protective mattress covers, moisture barrier cream, regular or antiseptic wipes (if a medical need is documented), sheets, towels and washcloths (if MN);
  • nutritional supplements;
  • enteral feeding formulas and supplies;
  • mouth swabs and toothettes;
  • diabetic supplies (strips, lancelets and syringes);
  • Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repairs;
  • stethoscopes, blood pressure monitors and thermometers for home use;
  • blood glucose monitors;
  • medical alert bracelets;
  • sharps or biohazard containers;
  • anti-embolism hose/stockings, such as thromboembolic disease hose; and
  • approved enemas, if not available through the Medicaid state plan or other TPRs.

Other

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare/Medicaid can cover hospital beds and specialty mattresses. Specialty sheets, such as hospital bed sheets, may be covered.

The STAR+PLUS HCBS program will pay for a Geri-chair if the member is alert, oriented and able to remove the tray table without assistance and as desired. Otherwise, the Geri-chair is considered a restraint and the STAR+PLUS HCBS program does not pay for restraints.

Gloves

Gloves may be purchased through the STAR+PLUS HCBS program for family or caregiver use in the care of a member with incontinence, or if the member has an active infectious disease that is transmitted via body fluids. Examples of active infectious diseases that qualify are Methicillin-resistant Staphylococcus aureus (MRSA) and hepatitis. Gloves may be purchased for family or caregiver use to provide wound care to protect the member. Documentation by the MCO-contracted provider must support the need of gloves to be left at the residence and for family or caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his or her approval.

Adaptive Aid Exclusions

The following are examples of items that may not be purchased using STAR+PLUS HCBS program funds. These items include, but are not limited to:

  • hot water heater;
  • combination heater, light and exhaust fan;
  • heating and cooling system filters;
  • non-adapted appliances, such as refrigerators, stoves, dryers, washing machines and vacuum cleaners;
  • water filtration systems;
  • central air conditioning and heating;
  • multiple air conditioning units to cover an individual's residence;
  • non-adapted home furnishings to include (except as allowed through Transition Assistance Services (TAS) or Supplemental Transition Support):
    • cooking utensils;
    • non-hospital bed mattresses and springs, including Adjustamatic, Craftmatic, Tempur-Pedic®, Posturepedic and Sleep Number® beds;
    • pillows (excluding neck pillows and support wedge pillows);
  • electrical heating elements (heating pads, electric blankets);
  • recreational items, equipment and supplies including:
    • bicycles and tricycles (2, 3 or 4 wheels);
    • helmets for recreational purposes;
    • trampolines;
    • swing sets;
    • bowling and fishing gear;
    • karaoke machines;
    • entertainment systems;
    • off-road recreational vehicles;
  • memberships to gyms, spas, health clubs or other exercise facilities;
  • communication items, including:
    • telephones (standard, cordless or cellular);
    • pagers;
    • pre-paid minute cards;
    • monthly service fees;
  • computers for the following justifications:
    • educational purposes;
    • self-improvement/employment purposes;
    • improvement of general computer skills;
    • internet and email access;
    • games and fun/craft activities;
  • office equipment and supplies to include:
    • fax machines;
    • printers/copiers;
    • scanners;
    • internet and email services;

Note: An individual accessing the Consumer Directed Services (CDS) option may purchase office equipment and supplies through the CDS budget.

  • gloves for universal precautions, or gloves that are used by MCO contracted provider, an adult foster care (AFC) provider or any contracted provider staff;
  • personal items for ADLs, such as hygiene products including soap, waterless soap, toothbrush, toothpaste, deodorant, powder, shampoo, lotions (except moisture barrier products), feminine products (except when documented for use as an incontinence supply), manual razors, washcloths, towels, bibs and first-aid supplies;
  • clothing items;
  • food;
  • bottled water (for drinking and cooking);
  • nutritional drinks and products, such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, nutrition and protein bars, breakfast cereals;
  • vitamins, minerals and herbal supplements and over-the-counter drugs;
  • title, license and registration for trailers or vehicles;
  • wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports;
  • vehicle repairs, as part of normal maintenance; repairs are part of normal vehicle maintenance and cannot be covered. Installation of heavy-duty shocks as required by a lift installation may be included as part of the vehicle modification. trailers (including taxes) for transporting wheelchairs or scooters;
  • experimental medical treatment and therapies, such as equestrian therapy; and
  • installation of gas or propane lines.

 

6420 Approval of Adaptive Aids and Medical Supplies

Revision 21-2; Effective August 1, 2021

 

In the initial pre-enrollment assessment and at reassessment, the managed care organization (MCO) service coordinator identifies the basic needs of the member for adaptive aids and STAR+PLUS Home and Community Based Services (HCBS) program medical supplies along with the estimated costs on Form H1700-1, Individual Service Plan. The MCO must provide documentation supporting the medical need for all adaptive aids and medical supplies. The documentation must be provided by the member's ordering, referring or prescribing provider. This can be a physician, physician assistant, nurse practitioner, registered nurse (RN), physical therapist, occupational therapist or speech pathologist. The service coordinator must use Form H1700-2, Individual Service Plan – Addendum, to document medical need and the rationale for purchasing the item(s).

Adaptive aids and medical supplies are approved for purchase as a STAR+PLUS HCBS program service by the MCO only if the documentation supports the requested item(s) as being necessary and related to the member's disability or medical condition.

The MCO determines if the documentation submitted is adequate, and makes the decision as to whether an adaptive aid or medical supply is needed and related to the member's condition. The MCO makes the final decision if the purchase is necessary and will be authorized on the individual service plan (ISP). The acute care benefit for any equipment or medical supplies must be expended before STAR+PLUS HCBS program benefits may be used.

If the member's request for a particular adaptive aid or medical supply is denied, the member must receive written notice of action of the denial of the specific item following the requirements outlined in the Uniform Managed Care Manual, Chapter 3.21.

If the member requests an item the MCO deems is not medically necessary or related to the member's disability or medical condition, the MCO must send a notice of action to the member.

For situations in which the member requests an adaptive aid or medical supply, and the item(s) are documented by the nurse or other medical professional to be medically necessary, the MCO has the option of approving the item(s). If not approved, the MCO must send a notice of action to the member.

The member may appeal the denial by filing an appeal with the MCO. The member does not receive the adaptive aid or medical supply unless the denial is reversed. If the denial is reversed, the item is added to the ISP. The cost of the item is reflected in the ISP in effect at the time of the appeal.

Service plans should be individualized to the member. All items must be related to the member's disability or medical condition and used to support or increase level of independence.

If the provider cannot deliver the adaptive aids by the appropriate time frames, the provider must notify the MCO via Form H2067-MC, Managed Care Programs Communication, and include the reasons the adaptive aid will be late. The MCO reviews the information to determine if the reason given for the delay is adequate or if additional intervention is necessary. It may be necessary for the MCO to discuss the reasons for the delayed delivery with the member and provider staff.

If the adaptive aid requested will not be delivered in the current ISP, the item must be transferred to the new ISP. If the authorization on the new ISP causes the ISP to exceed the annual cost limit, the nurse may authorize the service using the date the item was ordered by the provider as the date of service delivery and the provider may bill against the previous ISP.

 

6421 Lift Chair Approvals

Revision 21-2; Effective August 1, 2021

 

Lift chairs may be authorized as adaptive aids as part of the STAR+PLUS Home and Community Based Services (HCBS) program service array. Use the following procedures if attempting to purchase the lift chair using Medicare funding.

Once the managed care organization (MCO) determines a lift chair may be needed or is requested by the member, the MCO assesses the member to determine if the member meets all of the following criteria required for Medicare to pay for the lift mechanism:

  • The member must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  • The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the member's condition.
  • The member must be completely incapable of standing up from any chair in her or his home. Once standing, the member must have the ability to ambulate with or without assistance.

Member Does Not Meet All Criteria

If the member does not meet all of the Medicare criteria, the MCO completes Form H1700-2, Individual Service Plan – Addendum. The MCO should state the following on Form H1700-2, I. Medical Information, "Lift Chair: Plus Mechanism." Along with Form H1700-2, the MCO must obtain a:

  • prescription or statement signed by the physician certifying the need for the lift chair, specifically stating the member has difficulty or is incapable of getting up from a chair; and
  • statement by the physician or provider specifically stating that once standing, the member has the ability to ambulate or transfer with or without assistance.

The MCO approves the cost of the lift chair plus the mechanism if the request meets all criteria and the above documentation is received.

Member Meets All Criteria

If the MCO determines the member meets all of the criteria for Medicare to pay for the lift mechanism, the MCO:

  • approves the cost of the lift chair minus the mechanism;
  • authorizes the durable medical equipment provider to deliver the lift chair and bill Medicare for the mechanism; and
  • must document that Medicare is covering the mechanism.

If a request for a lift chair minus the mechanism is approved by the MCO, but the provider later requests additional funds for the mechanism denied by Medicare, the MCO may approve the request if it meets all STAR+PLUS HCBS program criteria. To avoid billing issues, the effective date of the change to add the funds for the lift mechanism must be the same as the effective date of the first change completed to approve the lift chair minus the mechanism.

 

6430 Effects of Changing MCOs on Adaptive Aids Procurements

Revision 18-2; Effective September 3, 2018

 

If a member changes to another managed care organization (MCO) while an adaptive aid is on order or in the process of being delivered, the MCO which authorized the service is responsible for payment and delivery of the adaptive aid.

 

6440 Temporary Lease and Equipment Rental

Revision 18-2; Effective September 3, 2018

 

Rental of equipment allows for repair, purchase or replacement of the equipment, or temporary usage of the equipment. The length of time for rental of equipment must be based on the individual circumstances of the member. If the medical professional and/or the member is not certain the medical equipment will be useful, the equipment should be rented for a trial or short-term period before purchasing the equipment.

The cost of renting equipment versus purchasing equipment may be explored, if you are currently renting the equipment. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment may be considered in the decision to rent or purchase. It may be more cost-effective, after renting for a period of time, to purchase the equipment instead of continuing to rent.

If the member prefers to buy the rented equipment, the managed care organization (MCO) must document the equipment functions properly and is appropriate for the member, so STAR+PLUS Home and Community Based Services (HCBS) program funds may be expended.

 

6450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies

Revision 18-2; Effective September 3, 2018

 

 

 

6451 Time Frames for Adaptive Aids

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized (except for vehicle modifications) to purchase the adaptive aid, counting from either the effective date of the individual service plan (ISP) form or the date the form is received, whichever is later. If delivery is not possible in 14 business days, the MCO must document the reason for the delay.

The MCO must notify the member and document notification of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business day following authorization. If the delivery does not occur by the new proposed date, the MCO must document any further delays, as well as document member notification, until the adaptive aids are delivered. The MCO must authorize a vehicle modification on the effective date of the member’s ISP. The MCO must work with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.

 

6452 Time Frames for Medical Supplies

Revision 18-2; Effective September 3, 2018

 

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive STAR+PLUS Home and Community Based Service (HCBS) program services. The provider must deliver medical supplies within five business days from the start date on the individual service plan (ISP). The member’s current supply of these items should be considered. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) before the fifth day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

If there is an existing supply of medical supplies on the service initiation date, the MCO must write "existing supply of needed medical supplies on hand" in the progress notes as verification that supplies were available to the member and did not require delivery at this time.

Stockpiling of medical supplies must not occur. Supplies, such as incontinence and wound care supplies not covered through Medicaid Home Health and needed on an ongoing basis, should be delivered so there is no more than a three-month supply in the member's home at a time.

 

6460 Co-Insurance and Deductibles

Revision 21-2; Effective August 1, 2021

 

Reimbursement for the cost of co-insurance for the purchase or rental of adaptive aids or the purchase of medical supplies reimbursed by Medicare or private health insurance is available if the following conditions are met:

  • the member does not have coverage under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs;
  • the adaptive aid or medical supply is listed in the service definition of this handbook or has been prior authorized by managed care organization (MCO) management; and
  • documentation submitted supports the necessity of the item(s) for the individual's disability or medical condition.

Reimbursement for the co-insurance amount to Medicare or private health insurance for therapy services or the rental of any adaptive aids is a cost-effective way to utilize third-party resources (TPRs). The cost of any co-insurance payment must be billed under adaptive aids.

For instances in which a member is not covered under the QMB or MQMB programs and cannot pay her or his premium deductible under a TPR for items covered under the STAR+PLUS Home and Community Based Services (HCBS) program, the deductible can be listed under adaptive aids on Form H1700-1, Individual Service Plan, for payment.

 

6470 Bulk Purchase of Medical Supplies

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) may choose to buy medical supplies in bulk. The cost of storing supplies can be reported on the annual cost report as an allowable expense. The medical supply is billed at the unit rate based on the invoice cost of the bulk purchase divided by the number of units purchased.

 

6500 Dental Services

Revision 18-2; Effective September 3, 2018

 

Dental services are those services provided by a dentist to preserve teeth and meet the medical needs of the member. Dental services must be provided by a dentist licensed by the State Board of Dental Examiners and enrolled as a Medicaid provider with Texas Medicaid & Healthcare Partnership (TMHP). The managed care organization (MCO) service coordinator arranges the needed dental services for STAR+PLUS Home and Community Based Services (HCBS) program members with licensed and enrolled dentists.

The MCO must discuss with the STAR+PLUS HCBS program member any available resources to cover the expense of dental services and consider those resources before authorizing dental services through STAR+PLUS HCBS program. If dental services are on the individual service plan (ISP), the MCO must authorize and coordinate a referral to a dental provider within 90 days of request by the member, unless there is documentation that the member requested a later date.

 

6510 Allowable Dental Services

Revision 18-2; Effective September 3, 2018

 

Allowable dental services include:

  • emergency dental treatment procedures necessary to control bleeding, relieve pain and eliminate acute infection;
  • preventative procedures required to prevent the imminent loss of teeth;
  • treatment of injuries to the teeth or supporting structures;
  • dentures and the cost of fitting and preparing for dentures, including extractions, molds, etc.; and
  • routine and preventative dental treatment.

The managed care organization (MCO) must ensure dental requests meet the criteria for allowable services before authorizing services, except in an emergency situation. Dental services are provided by STAR+PLUS Home and Community Based Services (HCBS) program when no other financial resource for such services is available and when all other available resources, with the exception of value-added services (VAS). VAS are not required to be used prior to waiver services. VAS vary by MCO.

The state allows a member to select a relative or legal guardian, other than a spouse, to be the member's provider for this service if the relative or legal guardian meets the requirements to provide this type of service. Payments for dental services are not made for cosmetic dentistry.

The annual cost limit of this service is $5,000 per individual service plan (ISP) year. The $5,000 cap may be waived by the MCO upon request of the member only when the services of an oral surgeon are required.

 

6520 Documentation of Dental Services by a Dentist

Revision 21-2; Effective August 1, 2021

 

The managed care organization (MCO) or its contractor must ensure all requests for dental treatments include documentation by a professional dentist of the need for dental services. A dentist must determine the medical necessity (MN) for dental treatment and submit a detailed treatment plan to the MCO to document the MN and all specific dental procedures to be completed. The dentist may not bill the STAR+PLUS Home and Community Based Services (HCBS) program member for the remainder of the cost over the approved amount.

Form H1700-2, Individual Service Plan – Addendum, must be completed by the MCO to document the medical need for requested STAR+PLUS HCBS program items or services. MN for dental services is completed by the professional dentist, as described above.

 

6530 Time Frames for Initiation of Dental Services

Revision 20-1; Effective March 16, 2020

 

The managed care organization (MCO) must work with the member to identify a dental provider or contracted provider no later than the first day of the member’s individual service plan (ISP). The MCO must send an authorization to the dentist within seven days of receipt of the dental treatment plan. Services must be initiated within 90 days of treatment plan development unless the member or dentist has a documented preference for a later initiation date.

 

6600 Minor Home Modifications

Revision 18-2; Effective September 3, 2018

 

Minor home modifications (MHMs) are those physical adaptations to a member’s home, required by the service plan, that are necessary to ensure the member's health, welfare and safety, or that enable the member to function with greater independence in the home. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies necessary for the member’s welfare. Excluded are those adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the member, such as carpeting, roof repair, central air conditioning, etc. Adaptations that add to the total square footage of the home are excluded from this benefit.

All services are provided in accordance with applicable state or local building codes. Modifications are not made to settings that are leased, owned or controlled by providers contracted with the managed care organization (MCO). The state allows a member to select a relative or legal guardian, other than a spouse, to be the member’s provider for this service if the relative or legal guardian meets the requirements to provide this type of service.

 

6610 Responsibilities Pertaining to Minor Home Modifications

Revision 16-1; Effective March 1, 2016

 

In order to ensure cost-effectiveness in the purchase of minor home modifications (MHMs), the managed care organization (MCO) must:

  • determine and document the needs and preferences of the member for the MHM; and
  • document the necessity for the MHM.

The MCOs have their own policies and procedures in regards to bidding, awarding contracts, doing inspections and completing MHMs.

 

6620 List of Minor Home Modifications

Revision 19-1; Effective June 3, 2019

 

The following minor home modifications (MHM) include the installation, maintenance and repair of approved items not covered by warranty:

  • Purchase of wheelchair ramps;
    • protective awnings over ramps;
  • Modifications or additions for accessible bathroom facilities;
    • wheelchair accessible showers;
    • sink modifications;
    • bathtub modifications;
    • toilet modifications;
    • water faucet controls;
    • floor urinal and bidet adaptations;
    • plumbing modifications and additions to existing structures necessary for accessibility adaptations;
    • turnaround space modifications;
  • Modifications or additions for accessible kitchen facilities;
    • sink modifications;
    • sink cut-outs;
    • turnaround space modifications;
    • water faucet controls;
    • plumbing modifications or additions to existing structures necessary for accessibility adaptations;
    • worktable or work surface adjustments or additions;
    • cabinet adjustments or additions;
  • Specialized accessibility or safety adaptations or additions, including repair and maintenance;
    • door widening;
    • electrical wiring;
    • grab bars and handrails;
    • automatic door openers, doorbells, door scopes, and adaptive wall switches;
    • fire safety adaptations and alarms;
    • medically necessary air filtering devices;
    • light alarms, doorbells for the hearing and visually impaired;
    • floor leveling, only when the installation of a ramp is not possible;
    • vinyl flooring or industrial grade carpet necessary to ensure the safety of the member, prevent falling, improve mobility, and adapt a living space occupied by an individual who is unable to safely use existing floor surface;
    • medically necessary steam cleaning of walls, carpet, support equipment and upholstery;
    • widening or enlargement of garage and/or carport to accommodate primary transportation vehicle and to allow persons using wheelchairs to enter and exit their vehicles safely;
    • installation of sidewalk for access from non-connected garage and/or driveway to residence, when existing surface condition is a safety hazard for the person with a disability;
    • porch or patio leveling, only when the installation of a ramp is not possible;
    • safety glass, safety alarms, security door locks, fire safety approved window locks, and security window screens; for example, for persons with severe behavioral problems;
    • security fencing for residence, for those persons with cognitive impairment or persons whose safety would be compromised if they wandered;
    • protective padding and corner guards for walls for members with impaired vision and mobility;
    • recessed lighting with mesh covering and metal dome light covers to compensate for violent aggressive behavior; for example, for persons with autism or mental illness;
    • noise abatement renovations to provide increased sound proofing; for example, for persons with autism or mental illness;
    • door replacement for accessibility only;
    • motion sensory lighting;
    • intercom systems for individuals with impaired mobility; and
    • lever door handles.

Ramps may be installed for improved mobility for use with scooters, walkers, canes, etc., or for members with impaired ambulation, as well as for wheelchair mobility. In some instances and according to supporting documentation, multiple modifications may be needed for accessibility and mobility, such as ramps and hand rails for members with impaired ambulation. There is no limit to the number of wheelchair ramps that can be authorized, provided the total cost does not exceed the cost limit, but documentation must support the justification for additional ramps as related to medical need or health and safety of the member.

Carbon monoxide detectors cannot be purchased under STAR+PLUS Home and Community Based Services (HCBS) program as a "fire safety adaptation and alarm."

Requests for items (or repair of items) or service calls that are considered routine home maintenance and upkeep cannot be approved.

Items that cannot be approved by the service coordinator include:

  • carpeting (other than industrial grade);
  • newly constructed carports, porches, patios, garages, porticos or decks;
  • electric fences;
  • landscaping and yard work or supplies;
  • roof repair or replacement;
  • gutters;
  • leaky faucet repair;
  • elevators;
  • house painting;
  • electrical upgrades and/or electrical outlets, unless needed to power adapted equipment or a safety hazard exists;
  • air duct cleaning and maintenance; and
  • pest exterminations.

Heating and cooling equipment may be approved as an adaptive aid. Installation of approved heating and cooling equipment is included in the cost of the adaptive aid. Support platforms are frequently used to provide support for cooling equipment installed in home windows. The support platforms attach in a clamp-like manner without fasteners. The cost and installation of support platforms are considered as an adaptive aid. The installation of heating and cooling equipment may require modification of the home (for example, additional wiring or widening of the windows). The modification of the home must be authorized as an MHM.

Flooring applications, including vinyl and industrial carpet, may not be authorized for adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the member.

 

6630 Minor Home Modification Service Cost Lifetime Limit

Revision 20-2; Effective October 1, 2020

 

There is a lifetime limit of $7,500 per member for this service and $300 yearly for repairs. Once the $7,500 cost limit is reached, only $300 per year per member, excluding associated fees, will be allowed for repairs, replacement or additional modifications. The managed care organization (MCO) is responsible for obtaining cost-effective modifications authorized on the member's individual service plan (ISP) that is more fully described in Section 6117, Service Planning, and Title 1 Texas Administration Code (TAC) §353.1153(c)(1). If a member’s ISP includes an identified need for minor home modifications (MHMs) that exceed the lifetime benefit limit, the MCO is permitted to exceed the cost limit without prior approval from Texas Health and Human Services Commission (HHSC). The MCO must not include any costs over the lifetime limit on any cost reports, claims, encounters or financial statistical reports.

If a member changes MCOs, the losing MCO must provide documentation to the gaining MCO related to any MHM expenditures. See Section 3413, Transferring from One MCO to Another Within Same Service Area.

 

6640 Landlord Approval for Minor Home Modifications

Revision 16-1; Effective March 1, 2016

 

When the member has a landlord or when the owner of the home is not the member, written approval prior to the initiation of any requested modification must be obtained.

 

6650 Time Frames for Minor Home Modifications

Revision 21-1; Effective May 1, 2021

 

When a minor home modification (MHM) is included in an individual service plan (ISP), the managed care organization (MCO) must ensure completion of the MHM within 90 business days after:

  • the start date of the ISP; or
  • the date of the ISP revision, if the service is added to the ISP after the ISP start date.  

The MCO must document and notify the member of any delay in completing the MHM, the reason for the delay and the new proposed completion date. If the provider does not complete the MHM by the new completion date, the MCO must document and notify the member about the additional delay. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely completion of the MHM.

 

6700 Employment Services

Revision 18-2; Effective September 3, 2018

 

 

 

6710 Employment Assistance

Revision 20-2; Effective October 1, 2020

 

Employment assistance is assistance provided to help a member locate paid employment in the community and includes:

  • identifying a member's employment preferences, job skills, and requirements for a work setting and work conditions;
  • locating prospective employers offering employment compatible with a member's identified preferences, skills and requirements; and
  • contacting a prospective employer on behalf of a member and negotiating the member's employment.

Documentation must be maintained in the member’s record that the service is not available to the member under a program funded under Section 110 of the Rehabilitation Act of 1973 or under a program funded by the Individuals with Disabilities Education Act (Title 20 U.S.C. §1401 et seq.).

An employment assistance service provider's credentials must satisfy one of these options:

Option 1:

  • a bachelor's degree in rehabilitation, business, marketing or a related human services field; and
  • six months of documented experience providing services to people with disabilities in a professional or personal setting.

Option 2:

  • an associate degree in rehabilitation, business, marketing or a related human services field; and
  • one year of documented experience providing services to people with disabilities in a professional or personal setting.

Option 3:

  • a high school diploma or general equivalency diploma (GED); and
  • two years of documented experience providing services to people with disabilities in a professional or personal setting.

 

6720 Supported Employment

Revision 18-2; Effective September 3, 2018

 

Supported employment is assistance provided, in order to sustain competitive employment, to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed. Supported employment includes adaptations, supervision, training related to a member's assessed needs and earning at least minimum wage (if not self-employed). In the state of Texas, this service is not available to members receiving waiver services under a program funded under Section 110 of the Rehabilitation Act of 1973. Documentation is maintained in the member's record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).

A supported employment service provider's credentials must satisfy one of these options:

Option 1:

  • a bachelor's degree in rehabilitation, business, marketing or a related human services field; and
  • six months of documented experience providing services to people with disabilities in a professional or personal setting.

Option 2:

  • an associate's degree in rehabilitation, business, marketing or a related human services field; and
  • one year of documented experience providing services to people with disabilities in a professional or personal setting.

Option 3:

  • a high school diploma or State of Texas Certificate of High School Equivalency; and
  • two years of documented experience providing services to people with disabilities in a professional or a personal setting.

Section 7000, STAR+PLUS HCBS Program and Services

Section 7000, STAR+PLUS HCBS Program and Services Anonymous (not verified) Fri, 07/22/2016 - 09:30
Body

Revision 21-2; Effective August 1, 2021

 

7100 Adult Foster Care

Revision 18-2; Effective September 3, 2018

 

 

 

7110 Introduction

Revision 20-1; Effective March 16, 2020

 

Adult foster care (AFC) provides 24-hour living arrangements and personal care services and supports for persons who, because of physical or behavioral conditions, are unable to live independently. Services and supports may include assistance and/or supervision with daily living, including meal preparation, housekeeping, companion services, personal care, nursing tasks and provision of, or arrangement for, transportation. The STAR+PLUS Home and Community Based Services (HCBS) applicant or member who chooses AFC must reside with a contracted STAR+PLUS HCBS program AFC home provider that meets the minimum standards and licensure requirements found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

AFC home providers must be contracted either directly with the member’s managed care organization (MCO) or with an AFC provider agency contracted with the member’s MCO. The individual qualified to provide AFC (AFC home provider) must be the primary caregiver. AFC home providers must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. AFC home providers may serve up to three adult residents in a qualified AFC home without being licensed as a personal care home or assisted living facility (ALF), and may be the AFC home provider’s home or the STAR+PLUS HCBS program applicant’s or member’s home. AFC home providers with four or more residents, which are also contracted with the Texas Health and Human Services Commission (HHSC), are required to have a Type C Personal Care Home license. AFC homes with four to eight AFC residents must be licensed as an ALF, with limitations on the number of residents at each level who may reside in the home. The three levels of eligibility for AFC are explained in Section 7133, Classification Levels of Adult Foster Care Members. ALF licensure requirements are found in Title 26 Texas Administrative Code (TAC), Chapter 553.

Any reference to “resident” includes members receiving services in the STAR+PLUS HCBS program and AFC or private pay individuals. AFC home providers may serve a combination of STAR+PLUS HCBS program members and private pay individuals in a qualified or licensed AFC home as long as the AFC home provider continues to meet the minimum standards specified in Appendix XXIV, and additional other standards may be specified by the MCO.

When the AFC home provider moves in with the STAR+PLUS HCBS program member receiving AFC in the member’s home, the AFC home enrollment requirements indicated with an asterisk in Appendix XXIV may be waived at the discretion of the MCO or the MCO-contracted AFC provider agency, as appropriate. Other minimum standards, excluding home safety requirements, may be waived at the discretion of the MCO, or upon the recommendation by the MCO-contracted AFC provider agency as long as the MCO-contracted AFC provider agency has completed a home assessment and concluded the member’s needs can be appropriately met through the STAR+PLUS HCBS program and AFC-specific services. Such conclusions must be documented by the MCO-contracted AFC provider agency and approved by the MCO.

The MCO is responsible for ensuring the AFC member receives all necessary AFC services, including the authorization of other needed services and nursing tasks.

STAR+PLUS HCBS program AFC members are required to pay for their own room and board costs and, if able, contribute to the cost of AFC services through a copayment to the AFC home provider. The only time room and board is not required is when the AFC home provider moves in with the member and the member's home becomes the AFC home. Room and board arrangements must be documented in the member’s case file by the MCO or by the MCO-contracted AFC provider agency.

If an AFC home is contracted with HHSC to provide services to an applicant or member receiving AFC through HHSC, the MCO or the MCO-contracted provider agency may request a copy of the AFC home and AFC home provider qualification documents from HHSC, if applicable. These documents contain HHSC findings regarding the qualifications of the AFC home and AFC home provider.

 

7111 Purpose

Revision 18-2; Effective September 3, 2018

 

The purpose of the STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) is to promote the availability of appropriate services in a home-like environment for members who are aging and who have disabilities to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of a member.

The STAR+PLUS HCBS program requires each AFC member to have enough living space to guarantee his or her privacy, dignity and independence.

 

7112 MCO Contracting Options

Revision 18-2; Effective September 3, 2018

 

The managed care organization (MCO) provides STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) through one of the two contracting methods:

  • Contracting with an individual AFC home provider; or
  • Contracting with an AFC provider agency that is responsible for:
    • qualifying the AFC home and AFC home provider;
    • ensuring ongoing compliance with AFC requirements and minimum standards found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers, unless waived as described in Section 7110, Introduction; and
    • reporting any significant change in the member’s needs or status to the MCO.

If the MCO contracts with an AFC provider agency, the MCO has oversight over the AFC provider agency. The MCO retains responsibility for its member(s).

 

7113 Adult Foster Care Services

Revision 19-1; Effective June 3, 2019

 

The adult foster care (AFC) home provider must provide services, supports and supervision, as needed, around the clock in an AFC home that has either been qualified based on the minimum standards or licensed by the Health and Human Services Commission (HHSC) (for homes serving four or more residents). Services may include:

Personal assistance services (PAS) Help with activities related to the care of the member's physical health that includes but is not limited to bathing, dressing, preparing meals, feeding, exercising, grooming (routine hair and skin care), toileting and transferring/ambulating.

A STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) member may not receive STAR+PLUS HCBS program PAS while the member is a resident in a STAR+PLUS HCBS program AFC home. Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and any addendums to Form H2060 are completed by the managed care organization (MCO) to determine the needed tasks for completion by the AFC home provider. The MCO must provide a copy of the required PAS tasks to the AFC home provider and to the MCO-contracted AFC provider agency, if applicable.

Transportation — Arrangement of and/or direct transport of members to meet their basic needs for food, clothing, toiletries, medications, medical care and necessary therapy.

Supervision — Periodic checks or visits by the provider to the member throughout the 24-hour period to assure the member is well and safe. For some members with more intensive medical needs or behavior problems, more frequent supervision is required.

Meal preparation — Preparation or provision of meals adequate to meet the needs of the member.

Housekeeping — Activities related to housekeeping that are essential to the member's health and comfort, such as changing bed linens, housecleaning, laundry, shopping, arranging furniture, washing dishes and storing purchased items.

AFC services, with the exception of 24-hour supervision that is provided to all STAR+PLUS HCBS program AFC members, are provided on an "as needed" basis, with the flexibility to meet the member's needs in the least restrictive way possible. For example, STAR+PLUS HCBS program AFC members may not need assistance with medication or help with transportation, but the services are available to all STAR+PLUS HCBS program members in AFC homes. PAS tasks must be provided as identified on Form H2060 and any addendums to Form H2060. The AFC home provider may provide more services for the member than are authorized, as the changing needs of the member may warrant, but may not reduce or discontinue services without prior consultation with the MCO.

STAR+PLUS HCBS program members, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to non-emergency medical transportation is available to members through the Medical Transportation program.

 

7114 Other Long Term Services and Supports Available to Adult Foster Care Members

Revision 21-2; Effective August 1, 2021

 

The managed care organization (MCO) may provide or arrange for the provision of the following services.

Adaptive Aids and Medical Supplies — Medical equipment and supplies that include devices, controls or appliances specified in the plan of care (POC) that enable individuals to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live.

Nursing Services — Services for members may be provided through the STAR+PLUS Home and Community Based Services (HCBS) program. Nursing services are assessment, planning and interventions provided by a person licensed to engage in professional nursing practice as a registered nurse (RN) or licensed vocational nursing (LVN) by the Texas Board of Nursing (BON) or licensed in a state that has adopted the Nurse Licensure Compact.

Minor Home Modifications (MHMs) — Services that assess the need, arrange for, and provide modifications and/or improvements to a residence to enable the member to reside in the community and to ensure safety, security and accessibility. MHMs are limited to those modifications identified and approved by the MCO on the individual service plan (ISP).

If the adult foster care (AFC) home is the member’s home, the member must agree to have modifications made to the home. If the AFC home provider is the owner of the home, the AFC home provider must agree to have modifications made to the home. If the AFC home provider is the lessee of the home, the owner must be contacted and apprised of the needed modifications. Permission to make the modifications must be obtained from the home owner in writing and kept with Form H1700-2, Individual Service Plan – Addendum.

When the AFC home provider and member or STAR+PLUS HCBS program applicant meet to interview each other and complete Form 2327, Individual/Member and Provider Agreement, the MHMs must be listed in "Miscellaneous Arrangements" if the AFC home is not the member’s home. Both the member and the AFC home provider must sign Form 2327 agreeing to all included information and stipulations.

To save the member from spending his or her allocation for MHMs unnecessarily, a minimum grace period of 30 days must be allowed for the member to adjust to the AFC placement before any modifications are begun. If the health or safety of the member is jeopardized without the necessary modifications upon entry into the AFC home, a waiver of the 30 days can be made based on the recommendations of the interdisciplinary team (IDT) and approved by the MCO.

MHMs remain in a STAR+PLUS HCBS program AFC home even if the member for whom the modifications were made permanently leaves the home.

Dental Services — Services provided by a licensed dentist to preserve teeth and meet the dental need of the member.

Occupational Therapy (OT) — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living (ADLs), education, work, play, leisure and social participation. Services consist of the full range of activities provided by an OT or a licensed occupational therapy assistant under the direction of a licensed occupational therapist and within the scope of his/her state licensure.

Physical Therapy (PT) — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculoskeletal systems. Services consist of the full range of activities provided by a physical therapist or a licensed physical therapist assistant under the direction of a licensed physical therapist and within the scope of his/her state licensure.

Speech Therapy (ST) — The evaluation and treatment of impairments, disorders or deficiencies related to a member’s speech and language. Services include the full range of activities provided by a speech and language pathologist under the scope of the pathologist's state licensure.

Cognitive Rehabilitation Therapy (CRT) — A service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. CRT is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Employment Assistance (EA) Services — Services that assist the member with locating competitive employment or self-employment.

Supported Employment (SE) Services — Services that assist the member with sustaining competitive employment or self-employment.

Day Activity and Health Services (DAHS) — Includes nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed or certified by the Texas Health and Human Services Commission (HHSC).

Each of the above services is provided according to the needs of the member as identified on the ISP, with the exception of DAHS, which is not included on the ISP. The MCO makes referrals for DAHS, coordinates delivery and advises the AFC home provider or MCO-contracted provider agency of any updates to the ISP or referrals for DAHS. Members who have nursing needs may be able to obtain nursing services at a DAHS facility. The MCO service coordinator will work with the AFC home provider or provider agency, if applicable, and the member to determine where the member’s needs can be most appropriately met. STAR+PLUS Home and Community Based Services (HCBS) program members residing in an AFC home without an RN as the AFC home provider may receive up to 10 units of DAHS per week. For Level III AFC homes, refer to Section 7133.2, AFC Homes Corresponding to AFC Member Levels, for DAHS eligibility.

 

7120 Minimum Standards for All Adult Foster Care Homes and Home Providers

Revision 18-2; Effective September 3, 2018

 

All adult foster care (AFC) homes and AFC home providers must be qualified initially and annually thereafter in accordance with the minimum standards outlined in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

 

7121 AFC Homes with Four or More Residents and Members

Revision 20-1; Effective March 16, 2020

 

An adult foster care (AFC) home provider must obtain an assisted living facility (ALF) license if the AFC home provider wants to serve four or more private pay residents and/or members. The AFC home provider may apply for an ALF license from the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The license must be renewed annually and requires an annual fee. Licensing standards for various types of AL facilities are found in Title 26 Texas Administrative Code (TAC), Chapter 553.

The AFC home provider must submit a copy of the ALF license to the managed care organization (MCO) or MCO-contracted AFC provider agency before being credentialed and upon renewal. The AFC home provider must report to the MCO or MCO-contracted AFC provider agency any problem(s) identified by HHSC Regulatory Services. AFC home providers must meet all applicable requirements in the minimum standards for AFC. AFC home providers with an AL license must serve no more than a total of eight adult residents in a small group home.

AFC homes of four or more residents, without an HHSC contract, are also subject to the following two sets of regulations:

  • Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers; and
  • Licensing Standards for Assisted Living Facilities, found in Title 40 TAC, Chapter 92.

The stricter requirements apply when requirements of the two sets of regulations conflict. For example, an AFC home licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of members currently residing in the facility.

If the MCO uses a contracted AFC provider agency, the contracted AFC provider agency must provide copies of any licenses for AFC homes of four or more residents when the MCO requests them.

 

7122 Small Homes for One to Three Residents and Members

Revision 18-2; Effective September 3, 2018

 

An adult foster care (AFC) home provider who serves up to three residents, including STAR+PLUS Home and Community Based Services (HCBS) program members, may be a member's relative, excluding the spouse. While these small homes do not require licensure, AFC homes and AFC home providers must meet the standards found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers. As outlined in Section 7110, Introduction, if the AFC home provider moves into the AFC member's home, AFC home requirements in Appendix XXIV may be waived at the discretion of the managed care organization (MCO) or MCO-contracted AFC provider agency.

 

7123 MCO Responsibilities

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) responsibilities include:

  • providing information to interested applicants about potential adult foster care (AFC) homes and coordinating visits to the homes;
  • developing an individual service plan (ISP);
  • acting as coordinator of the interdisciplinary team (IDT);
  • authorizing AFC services;
  • evaluating and coordinating services for the member;
  • notifying the member, AFC home provider and AFC provider agency, if applicable, of room and board and copayment amounts, as outlined in Section 3236, Copayment and Room and Board;
  • processing changes and conducting annual reassessments of the member;
  • completing an assessment to ensure the potential or existing member’s needs can be met in a particular home;
  • recruiting, contracting and credentialing AFC homes and home providers;
  • processing AFC home and home provider applications;
  • orienting and training AFC home providers;
  • approving private pay residents;
  • ensuring initial and ongoing compliance with AFC minimum standards;
  • conducting annual re-qualification reviews of the AFC home and home provider;
  • conducting administrative reviews; and
  • processing AFC provider payments.

An MCO may also choose to contract with an AFC provider agency to facilitate AFC home and home provider management on behalf of the MCO. When this occurs, the contracted AFC provider agency is responsible for provisions stipulated in its contract with the MCO. However, the MCO retains overall responsibility for all requirements related to AFC service delivery and oversight of the MCO-contracted AFC provider agency and the member.

 

7130 Adult Foster Care Eligibility

Revision 18-2; Effective September 3, 2018

 

To be eligible for adult foster care (AFC), applicants and members must meet basic eligibility requirements for STAR+PLUS Home and Community Based Services (HCBS) program services as well as specific requirements related to AFC. Basic eligibility requirements for the STAR+PLUS HCBS program can be found in Section 3230, Financial Eligibility, and Section 3240, Waiver Requirements. AFC applicants or members are identified for the STAR+PLUS HCBS program AFC based on their assessed needs for care. Refer to Section 7133, Classification Levels of Adult Foster Care Members.

 

7131 AFC Intake, Assessment and Response to Request for Services

Revision 19-1; Effective June 3, 2019

 

Adult foster care (AFC) is appropriate for individuals who, because of physical, mental or behavioral conditions, are unable to live independently and who need and desire the support and security of family living. AFC may be appropriate for individuals who are:

  • seeking alternatives to facility-based care; or
  • interested in leaving institutional care but are unable to resume independent living.

When discussing AFC as an option for applicants or members, the managed care organization (MCO) or MCO-contracted AFC provider must explain the room and board requirements and ensure the applicant or member understands that he or she must pay a portion of the monthly income for room and board. If the AFC home provider moves into the member’s home, payment for room and board does not apply. The MCO must also explain that some members residing in an AFC home are additionally required to contribute to the cost of their AFC services by paying a copayment, regardless of whether the AFC home is the member's home. Refer to Section 7152, Copayment and Room and Board Requirements, for additional information.

 

7132 Assessing Potential Adult Foster Care Homes

Revision 21-2; Effective August 1, 2021

 

If the applicant or member appears to meet eligibility criteria, the managed care organization (MCO) or MCO-contracted provider agency provides information to the applicant or member about adult foster care (AFC) services, including potential AFC home providers and AFC homes. The MCO or MCO-contracted AFC provider agency can arrange visits to appropriate AFC homes or, if the applicant or member is capable or has family/supports available, the applicant or member and family may make the arrangements to visit potential AFC homes.

The purpose of the visits to potential AFC homes is to let the applicant or member assess the home and let the AFC home provider assess if the applicant or member will be an appropriate resident for the AFC home. The MCO or MCO-contracted AFC provider agency may contact the AFC home provider and share information about the applicant or member, including the applicant's or member’s particular needs and characteristics, to ensure the potential AFC home provider is fully aware of the responsibilities involved in caring for the applicant or member and to prevent a potential mismatch of the applicant or member and the AFC home provider.

As part of the assessment, MCO service coordinators must determine if the applicant or member can be left alone for up to three hours and document this on Form H1700-2, Individual Service Plan – Addendum. The MCO service coordinator must inform the AFC home provider directly of this or through the MCO-contracted AFC provider agency, if applicable. If the applicant or member cannot be left alone, the AFC home provider will be responsible for providing or arranging for 24-hour supervision.

To guide the applicant or member in the selection of the AFC home, the MCO or MCO-contracted AFC provider agency relies on the recommendation of the registered nurse (RN) completing the STAR+PLUS Home and Community Based Services (HCBS) program assessment regarding the needs of the applicant or member. Refer to Section 7133, Classification Levels, below. If the MCO is not contracting with an AFC provider agency, the MCO’s RN must also assess the ability of the applicant or member to safely evacuate the AFC home.

 

7133 Classification Levels

Revision 18-2; Effective September 3, 2018

 

Classification (payment levels) for adult foster care (AFC) members are used for identification of potential AFC applicant or member appropriateness, and are based on the member’s assessed needs for care as determined through the required face-to-face assessments for STAR+PLUS Home and Community Based Services (HCBS) program services and the individual service plan (ISP) completed by the managed care organization (MCO) service coordinator. Determine and document whether an applicant or member is appropriate for AFC based on the applicant’s or member’s condition and behavior. Develop a service plan appropriate to the applicant’s or member’s needs and specific to a given AFC home provider, taking into consideration the AFC home provider’s capabilities. The MCO-contracted AFC provider agency, if applicable, would be involved in a determination of AFC home provider capabilities.

 

7133.1 Levels of Adult Foster Care Members

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) will use the Medical Necessity and Level of Care (MN/LOC) assessment, Form H6516, Community First Choice Assessment, or  Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums. The registered nurse (RN) service coordinator determines a member’s classification level for adult foster care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) (transferring, walking, dressing, eating, toileting, bathing), and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member.

Below are the classification levels of a member’s daily assistance or supervision requirements.

Level I AFC Member

A member who needs assistance with identified needs including a minimum of:

  • one ADL and behavior(s) that occur at least once a week; or
  • two ADLs.

Level II AFC Member

A member who needs assistance with identified needs including a minimum of:

  • two ADLs and behavior(s) that occur at least once a week; or
  • three ADLs.

Level III AFC Members

A member who needs assistance with identified needs including a minimum of:

  • three ADLs and behavior(s) that occur at least once a week; or
  • four ADLs.

 

7133.2 AFC Home Provider Corresponding to AFC Member Levels

Revision 19-1; Effective June 3, 2019

 

The adult foster care (AFC) home provider must be able to meet the member’s needs in the AFC setting in conjunction with the STAR+PLUS Home and Community Based Services (HCBS) program and other available supports. If the member’s needs for care exceed the capability of the AFC home provider, the managed care organization (MCO) service coordinator must reassess the member and offer alternate care options.

The AFC home provider who is a licensed registered nurse (RN) and the AFC home provider RN substitute must provide proof of current licensure to the MCO or MCO contracted provider agency (if applicable) initially and annually thereafter.

The MCO RN service coordinator will complete the Medical Necessity and Level of Care (MN/LOC) assessment, both initially and annually. AFC home providers with STAR+PLUS HCBS program members may not care for more than one totally dependent AFC resident. The MCO RN service coordinator must respond to a request for a change in services within the individual service plan (ISP) year.

Health maintenance activities (HMAs) are tasks which may be exempt from registered nurse delegation based on the MCO RN assessment. HMAs may enable the member to remain in an independent living environment and go beyond activities of daily living (ADLs) because of the higher skill level required to perform them (as found in the Texas Board of Nursing rules in 22 Texas Administrative Code §225.4(8)).

For members residing in Level I, Level II and Level III AFC homes not operated by an RN, the skilled nursing needs must be:

  • identified by the MCO service coordinator as HMAs;
  • purchased as nursing services on the ISP;
  • provided by Medicare, Medicaid home health or other resource;
  • met by a nurse at a Day Activity and Health Services (DAHS) facility; or
  • a combination of the above options.

For members residing in Level I, Level II and Level III AFC homes operated by an RN, the skilled nursing needs must be:

  • identified by the MCO RN service coordinator as HMAs;
  • met by the AFC home provider nurse or nurse substitute;
  • provided by Medicare, Medicaid home health or other resource; or
  • a combination of the above options.

AFC members receiving nursing services and residing with an RN who is the AFC home provider are not eligible to receive day activity and health services (DAHS).

 

7134 Adult Protective Services and Adult Foster Care

Revision 18-2; Effective September 3, 2018

 

This section provides details regarding when Adult Protective Services (APS) staff request adult foster care (AFC) as a resource for individuals who may benefit from AFC.

 

7134.1 Placement of Adult Protective Services Clients in Adult Foster Care

Revision 19-1; Effective June 3, 2019

 

Adult Protective Services (APS) may want to move an adult foster care (AFC) individual into an AFC home where a STAR+PLUS Home and Community Based Services (HCBS) program member resides. The managed care organization (MCO) must approve and ensure the APS individual is appropriate and document this in the MCO case record. This includes determining the:

  • APS individual's medical and behavioral health needs are met;
  • capacity of the AFC home provider to meet the APS individual's needs; and
  • compatibility of service delivery to the APS individual with the delivery of services to existing AFC members who may reside in the AFC home.

If the MCO determines the APS individual's placement is not appropriate, the APS individual may not move into the AFC home and the APS worker must make other living arrangements.

 

7134.2 Adult Protective Services Investigations of Adult Foster Care Providers

Revision 19-1; Effective June 3, 2019

 

Any time managed care organization (MCO) staff of an MCO-contracted adult foster care (AFC) provider agency suspect abuse, neglect or exploitation (ANE) of an AFC member in an unlicensed AFC home, the staff must report it immediately to Adult Protective Services (APS). Reports of ANE in a licensed AFC home must be made to the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The MCO-contracted AFC provider agency must also notify the MCO.

If reports of ANE taking place in an unlicensed AFC home are made to APS by other parties, the MCO or MCO-contracted AFC provider agency staff may not be notified of member allegations against an AFC provider until after the allegations have been validated. However, APS staff may ask the MCO or MCO-contracted provider agency to assist with the delivery of alternative services during the course of the investigation if the alleged mistreatment poses an immediate threat to the safety of the member or other AFC residents.

The MCO handles disenrollment and corrective actions against the AFC home provider, as appropriate. HHSC takes necessary licensure actions for licensed AFC homes. If HHSC terminates the licensure of an AFC home and the MCO is unable to find a suitable alternative residence for the member, the member is referred to APS for assistance in moving from the AFC home.

A member in an unlicensed AFC home who has the capacity to consent may decide not to move from the AFC home, even though the allegation has been validated. In this instance, the member's AFC services will be denied, payments to the home will terminate and an MCO-contracted provider agency will withdraw from supporting ongoing management of the home. However, the member may continue to reside in the unlicensed AFC home by making private pay arrangements at that home.

If a member residing in an unlicensed AFC home who does not appear to have the capacity to consent refuses to move from an unlicensed AFC home in which an individual identified as the perpetrator in a case of validated ANE lives and is in a state of ANE, the MCO must make a referral to APS. The MCO-contracted AFC provider agency staff must send a referral to the MCO and APS if the agency staff identify this situation.

If the substantiated allegation of ANE is in a licensed AFC home, the perpetrator must be removed from the AFC home and the license holder must submit to HHSC a plan for the protection of the health and safety of all residents. The resident will not be required to move.

 

7135 Private Pay Individuals in Adult Foster Care

Revision 18-2; Effective September 3, 2018

 

Some adult foster care (AFC) home providers may wish to take private pay individuals. The AFC home provider must contact the managed care organization (MCO) when considering the admission of a private pay individual before he or she is accepted in the AFC home. The purpose of the approval is to determine the:

  • appropriateness of AFC for the private pay individual based on the individual’s condition and behavior;
  • capacity of the AFC home to meet the private pay individual’s needs; and
  • compatibility of service delivery to the private pay individual and the delivery of services to AFC members.

If the MCO determines placement in an AFC home is inappropriate, the AFC home provider cannot accept the private pay individual. Any issues regarding placements must be resolved by the MCO.

 

7140 Adult Foster Care Managed Care Organization Procedures

Revision 18-2; Effective September 3, 2018

 

This section provides details for a managed care organization (MCO) when determining an applicant's eligibility for adult foster care (AFC) and for developing the applicant’s individual service plan (ISP).

 

7141 Eligibility Determination

Revision 18-2; Effective September 3, 2018 

 

To determine eligibility for adult foster care (AFC), the managed care organization (MCO) must determine the applicant or member meets all criteria for the STAR+PLUS Home and Community Based Services (HCBS) program and complete an assessment to determine the applicant’s or member’s classification level. If the AFC placement is with an individual AFC home provider contracted with the MCO, the MCO must also ensure the applicant or member has an agreement with an enrolled AFC home provider and the applicant or member and AFC home or home provider are appropriately matched per the classification and needs of the applicant or member before the MCO pays for AFC services. If an MCO contracts with an AFC provider agency to perform AFC management services, the MCO-contracted provider agency may perform activities related to the qualification of the home and the home provider before the MCO pays for AFC services. Refer to Section 7133, Classification Levels.

 

7142 Service Planning

Revision 19-1; Effective June 3, 2019

 

The member’s plan of care must address functional, medical, social and emotional needs and how the needs will be met by the adult foster care (AFC) home provider. The managed care organization (MCO) must assess whether other resources in the community should be used to meet specialized needs of the member. Use of those resources must be documented in the member’s plan of care.

The MCO must complete Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, to document the specific personal assistance tasks with which the AFC home provider must assist the member. The AFC home provider may provide more services for the member than are identified on Form H2060 as the changing needs of the member may warrant, but may not reduce or discontinue services without consultation with the MCO or MCO-contracted AFC provider agency.

Upon approval for AFC, the MCO determines if the member has any special needs that require additional monitoring in the AFC home. The MCO must document any special needs or interventions in the case record on Form 2327, Individual/Member and Provider Agreement. Use the "Other Special Arrangements" space under the "Miscellaneous Arrangements" section.

The MCO or MCO-contracted AFC provider agency contacts the member and the AFC home provider to arrange for the initial visit and a negotiated move-in date for the member or AFC home provider. If there are health concerns regarding the member, the MCO nurse may be consulted and a recommendation may be made for the member to have a physical or medical exam before moving into the AFC home. The MCO coordinates with the interdisciplinary team (IDT) and the MCO-contracted AFC home provider, if applicable, regarding the AFC member’s care.

 

7150 Finalizing the Member’s Plan of Care

Revision 19-1; Effective June 3, 2019

 

On or before the date the member begins to receive adult foster care (AFC) services, a face-to-face meeting with the member and the AFC home provider is required to discuss the member's plan of care (POC) and to complete Form 2327, Individual/Member and Provider Agreement. The interdisciplinary team (IDT), including the staff of the managed care organization (MCO)-contracted AFC provider, as applicable, and the member and/or family, authorized representative (AR) or guardian may be included in the meeting. The meeting should preferably take place in the AFC home.

The MCO must discuss the member's POC with the member and/or family, AR or guardian and reach understanding with them about how the AFC home provider will meet the member’s needs. This discussion should ensure the member and family, AR or guardian that the AFC home provider is adequately prepared to provide services to the member and that adjustments occur smoothly. The MCO must document the POC and any special needs of the member or special agreements between the member and AFC home provider on Form 2327.

If the applicant or member is already residing in the AFC home, Form 2327 must be completed by the MCO service coordinator face-to-face with the applicant or member and AFC home provider or provider agency, if applicable, before the MCO pays for AFC services initially and upon annual reassessment.

 

7151 Member and AFC Home Provider Agreement

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.

The MCO or the MCO-contracted adult foster care (AFC) provider agency reviews all of the information on the agreement with the member, family, authorized representative (AR) or guardian and the AFC home provider. All conditions of the agreement and the following topics must be covered in the discussion:

  • A full description of the care needs of the member and frequency of services needed.
  • The need for and frequency of supervision.
  • The beginning and ending date on Form 2327.
  • A detailed description of the rights and responsibilities of the member and the AFC home provider.
  • An explanation of the member's and AFC home provider's right to privacy and confidentiality.
  • The monthly dollar amount the member agrees to pay the AFC home provider for room and board, as documented on Form 2327.
  • The arrangements for a trust fund if the STAR+PLUS Home and Community Based Services (HCBS) program member requests such service from the AFC home provider. 
  • An inventory of the AFC member’s personal belongings.
  • The names, addresses and telephone numbers of the persons to be notified in an emergency, including the member's physician, family members and/or AR or guardian.
  • Any special habits and needs of the member and any special arrangements or agreements between the member and the AFC home provider.
  • Any additional training needs of the AFC home provider and methods to obtain that training.
  • The rights and responsibilities of both the member and the AFC home provider for notifying the MCO, MCO-contracted AFC provider agency, as applicable, of problems such as illnesses, adverse medication reactions, hospitalizations, acts of violence, accidents or complaints about abuse, neglect or exploitation. The Texas Health and Human Services Commission (HHSC) Managed Care Compliance & Operations (MCCO) must be notified if the member, MCO-contracted provider agency or AFC home provider have a complaint or issue regarding the health and safety of the member.
  • Other conditions that reflect changes in the member's condition that might affect the appropriateness of AFC services.

The MCO or MCO-contracted provider agency must fully discuss with the AFC home provider the potential for transition issues arising after the member moves into the AFC home or when the AFC home provider moves into the member’s home. The discussion should include notification procedures and suitable actions to be taken to address issues and resolve problems, and the impact of a new living situation on family and other residents in the home.

The member and the AFC home provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement. Form 2327 must be completed and signed before authorizing and reauthorizing AFC. Any significant changes to the terms of the agreement must be reported by the AFC home provider within five business days. Any incidents, as referenced in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers, must be reported by the AFC home provider to the MCO service coordinator assigned to the member, and the MCO-contracted AFC provider agency, as applicable, within 24 hours of the occurrence.

 

7152 Copayment and Room and Board Requirements

Revision 19-1; Effective June 3, 2019

 

Copayment and room and board are applicable to adult foster care (AFC) members as described in Section 3236, Copayment and Room and Board. If the AFC service is provided in the member’s own home, the member is not required to pay room and board. It is the responsibility of the managed care organization (MCO) to ensure the member and the MCO-contracted AFC provider agency, as applicable, are notified in writing on Form 2327, Individual/Member and Provider Agreement, when room and board is waived. It is the MCO-contracted AFC provider agency’s responsibility to notify the AFC home provider when room and board is waived. Copayment, if applicable to the member, may be waived.

If copayment is applicable, the AFC member's copayment amount is listed on Form H2065-D, Notification of Managed Care Program Services, which is sent to the member by Program Support Unit (PSU) staff and uploaded to TxMedCentral. Form H2065-D is used to report to the member the amount of the copayment for the first month of authorized service and subsequent months. The MCO furnishes a copy of Form H2065-D to the AFC home provider.

The room and board amount, as applicable, is entered on Form H2065-D and Form 2327. The member does not pay room and board if the AFC home provider moves in with the member into the member’s home. The MCO or MCO-contracted AFC provider agency must ensure the member and AFC home provider understand that the room and board arrangement with the AFC home provider is separate from the MCO payment for AFC services. The member pays the AFC home provider the room and board amount listed on Form 2327 and Form H2065-D. If the member is moving into the AFC home mid-month, the amount of room and board for the month is prorated and the member and AFC home provider will be advised of the prorated amount.

When the copayment and/or room and board amounts change, the MCO must notify the AFC home provider and the member of the new amount before the change, as described in Section 3239, Copayment Changes. The member must pay the copayment and room and board charge by the eighth day of the month. If the member does not pay the required fees, the member may not be eligible for STAR+PLUS Home and Community Based Services (HCBS) program AFC services.

The STAR+PLUS HCBS program AFC home provider must collect the copayment from the member. The AFC home provider must keep receipts for all copayments collected. The AFC home provider must deduct the copayment amount authorized on Form H2065-D from reimbursement claims submitted to the MCO or advise the MCO-contracted AFC provider agency of the amount collected. If a STAR+PLUS HCBS program AFC member does not pay the copayment and/or room and board, the MCO or MCO-contracted AFC provider agency must investigate the member's failure to pay, including contacting the member to learn the reason the fees were not paid. Even if there is a legitimate reason, such as the member's income check has not been received by the eighth day of the month, the member is still under obligation to pay the fees. Grievances between the member and the AFC home provider are not legitimate reasons for the member to withhold payments due. Such grievances must be resolved through the intervention of Texas Health and Human Services Commission (HHSC) Managed Care Compliance & Operations (MCCO) and the MCO.

If the member refuses to pay the fees or there is no legitimate reason for failing to pay, the MCO shall write a letter to the member or the member's authorized representative (AR) explaining the consequences of continued refusal to pay. If the member does not pay the required fees within 30 days of the due date, the MCO can terminate AFC services to the member. If STAR+PLUS HCBS program AFC is being delivered in the AFC home provider’s residence, the member can then be evicted from the home, according to local eviction ordinances and procedures.

 

7153 Trust Funds

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) must offer money management assistance by the adult foster care (AFC) home provider to the member and document when the member either accepted or refused the assistance. If the member expresses an interest in money management, the MCO documents the expressed interest on Form H2067-MC, Managed Care Programs Communication, and sends the form to the AFC home provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.

The AFC home provider must maintain trust fund records. The AFC home provider must:

  • have written permission from the member, his or her guardian, power of attorney, or applicable individual to handle the member’s personal financial affairs;
  • keep member trust accounts separate from the AFC home provider's operating accounts. The separate account must be identified "Trustee (name of the STAR+PLUS Home and Community Based Services (HCBS) program AFC home provider), Member's Trust Fund Account." If the AFC home provider maintains a trust fund, the AFC home provider must:
    • deposit the member's monthly income into the account; and
    • write a check for the copayment and the room and board payment out of the trust fund account into the AFC home provider's operating account. Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account;
  • make the member trust fund records available for review by the MCO or AFC home provider agency during work hours without prior notice;
  • not charge the member for services the AFC home provider is expected to provide for the member;
  • not charge the member for banking service costs if the member’s trust fund is in a pooled account;
  • obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the AFC home provider is handling. The AFC home provider must include at least the following in the records:
    • member's name;
    • identification of member's representative payee or responsible party;
    • admission date;
    • member's earned interest; and
    • transactions – the AFC home provider may choose one of the following options:
      • maintain records of the date and amount of each deposit and withdrawal, the name of the person who accepted the withdrawn funds and the balance after each transaction. Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his/her trust funds, the transactions or receipt must be signed by a witness other than the AFC home provider or employee/contractor of the provider; or
      • maintain signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his or her name, a witness other than the AFC home provider, employee or contractor of the provider must sign the transaction or receipt; and
  • distribute the interest earned on any pooled interest banking account in one of the following options:
    • prorated to each member on an actual interest earned basis; or
    • prorated to each member on the basis of his or her end-of-quarter balance.

The following information must be included on the receipt for all money that is received or deposited in the member’s trust fund:

  • member's name;
  • date the money was received;
  • source of the money;
  • amount received; and
  • amount returned to the member, if any.

All records pertaining to the member's trust fund must be kept in the manner designated above, and available for monitoring without notice.

 

7154 Hospital Leave

Revision 18-2; Effective September 3, 2018

 

If a member is receiving adult foster care (AFC) services in an AFC home which is not the member’s home, the member may be required to reserve the space during hospital stays by paying the daily bed hold charge, if the provider requires such a charge, which is the negotiated daily rate the managed care organization (MCO) pays the AFC home provider or MCO-contracted provider agency. The AFC home provider does not bill the MCO for the days the STAR+PLUS Home and Community Based Services (HCBS) program AFC member is hospitalized. The AFC member's bed hold charge constitutes the entire payment to the AFC home provider or MCO-contracted AFC provider agency when an AFC member is hospitalized.

During the initial home visit, the MCO or MCO-contracted AFC provider agency reviews the information regarding the AFC member's responsibility to pay a bed hold charge when away from the home and documents this on Form 2327, Individual/Member and Provider Agreement. Hospital leave does not apply when the AFC home provider moves into the member’s home.

 

7155 Authorization of Adult Foster Care

Revision 21-2; Effective August 1, 2021

 

After STAR+PLUS Home and Community Based Services (HCBS) program eligibility is established and all additional adult foster care (AFC) procedures are completed, the managed care organization (MCO) authorizes AFC on Form H1700-1, Individual Service Plan. Program Support Unit (PSU) staff send the member Form H2065-D, Notification of Managed Care Program Services.

The MCO sends the following completed documents to the AFC home provider and MCO-contracted AFC provider agency, if applicable:

  • a copy of Form H1700-1;
  • additional applicable ISP forms:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page; or
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment;
  • Medical Necessity and Level of Care Assessment; and
  • Form 2327, Individual/Member and Provider Agreement.

 

7160 Monitoring Quality of Care

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) registered nurse (RN) service coordinator will monitor the quality of care and services provided to meet the needs of the STAR+PLUS Home and Community Based Services (HCBS) program members receiving adult foster care (AFC) services. The service coordinator will appropriately address any issues identified to protect the health and safety of the member.

During regular monitoring visits, the MCO RN service coordinator must contact the MCO management and MCO-contracted AFC provider agency, if applicable, if the AFC home provider is not meeting the member's needs or the home provider requires additional support or training to meet the member’s needs. The AFC member's physical and medical condition must be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness.

Form 2327, Individual/Member and Provider Agreement (see No. 1 under Miscellaneous Arrangements), is used to document special monitoring schedules and other resources used in the plan of care (POC). When the AFC home provider moves in with the AFC member, it is the MCO's responsibility to ensure the AFC member's needs are being met, and there are no health and safety concerns. If concerns are reported or identified, the AFC member's rights must be protected and adjustments to the care plan made accordingly.

 

7170 Significant Changes

Revision 18-2; Effective September 3, 2018

 

It is the joint responsibility of the managed care organization (MCO) and the contracted adult foster care (AFC) home provider, or MCO-contracted AFC provider agency, to ensure the AFC member is in an appropriate setting to meet his or her needs. When the AFC member has a change in functional need, medical status or behavior, it is the responsibility of the AFC home provider to notify the MCO or MCO-contracted AFC provider agency within 24 hours. The MCO must follow up with the member and AFC home provider to determine if changes to the care arrangement are needed.

The MCO must give particular attention to members who have significant changes in functional need, medical status or behaviors that may mean AFC services are no longer appropriate. Family members and/or authorized representative (AR) or guardian must be alerted to these changes, and the MCO service coordinator should discuss with them and the member the potential for the member to remain in the AFC home. If the member has had a decline in his or her medical condition or functional ability, the MCO RN service coordinator should determine if a visit should be made to assess the member’s medical status.

Long-range care plans must be discussed fully with the member and/or family, AR or guardian and the AFC home provider to ensure that all are aware of the capabilities and limitations of AFC services for members with deteriorating medical or functional conditions. Members who become inappropriate for AFC must be advised of other available options. Assistance must be provided to members and family, AR or guardian in this decision process and with transfer activities when necessary. If the AFC home provider decides the member is no longer appropriate for AFC, the AFC home provider must contact the MCO. The MCO is responsible for preparing the member for transition when the member becomes inappropriate for a particular AFC home or AFC services.

 

7171 Termination of Adult Foster Care Services

Revision 19-1; Effective June 3, 2019

 

During the course of a member's stay in an adult foster care (AFC) home, the member may experience changes in his or her condition or the care required. If the member begins to need services that cannot be provided by the AFC home provider, the managed care organization (MCO) must consult with the AFC home provider regarding increased needs of the member to assure the necessary care is obtained. Another provider, such as a Home and Community Support Services Agency (HCSSA), may deliver skilled care in the AFC home.

If the skilled services provided in the home by the provider, such as an HCSSA, are not sufficient and other services are not available to support the member, the MCO, in conjunction with other members of the interdisciplinary team (IDT), should explore alternatives.

The AFC home provider is expected to take actions necessary if the member's condition deteriorates or the member is a threat to his or her own health and safety or the health and safety of others. The AFC home provider is required to notify the MCO and MCO-contracted AFC provider agency, as applicable, of actions taken on the same day of awareness. If necessary, the MCO must follow the procedures identified in Section 7172, Discharge and Termination Due to Health and Safety.

AFC home providers cannot reduce or terminate AFC services to members without the prior approval of the MCO and must follow procedures for providing a 30-day written notice, with an exception for a member whose behavior or condition threatens the health or safety of him or her or others. During the 30 days after written notice is provided to the member, the MCO is responsible for working with the member to assure alternative services are available.

Once a member is identified as inappropriate for AFC, the MCO must negotiate a time frame with the member, family, authorized representative (AR) or guardian and the AFC home provider for the member to have an alternate individual service plan (ISP). The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the member has been a threat to the health and safety of other(s) or has exhibited inappropriate behaviors where the member must move immediately, the MCO must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the member, the MCO must refer the member to Adult Protective Services (APS) to assist in locating appropriate placement.

If there is resistance to the move from the member, family, AR, guardian or the AFC home provider, additional support from the IDT may be required to resolve the problem. The MCO advises Program Support Unit (PSU) staff to send the member Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral to deny AFC services. The MCO follows up on this PSU action by advising the member and AFC home provider of the AFC services termination date specified on Form H2065-D. If the member transfers to another AFC home or STAR+PLUS Home and Community Based Services (HCBS) program living arrangement, the MCO must notify the member and AFC home provider of the change in services. If the member does not transfer to another AFC or STAR+PLUS HCBS program living arrangement and all STAR+PLUS HCBS program services are terminated, the MCO informs PSU staff by uploading Form H2067-MC to TxMedCentral. PSU staff send the member Form H2065-D and uploads a copy of the form to TxMedCentral within three business days of uploading Form H2067-MC. If services are not provided in the member’s home, the AFC home provider has the right to begin eviction proceedings as specified in the AFC home provider's resident rights and responsibilities. The MCO must ensure that the member and authorized representative understand the consequences of eviction. If the AFC home provider must use eviction procedures and the member has refused to make other living arrangements, the MCO must refer the member to APS.

If the member and AFC home provider decide that the member will remain in the home as a private pay member, the MCO must give approval. The MCO must also ensure the member and AFC home provider understand that there are no case management services or payment arrangements from the MCO for a private pay member.

Refer to Section 7172, Discharge and Termination Due to Health and Safety, below for more details on how to handle situations in which the AFC member threatens the health and/or safety of himself or herself or others in the AFC home.

 

7172 Discharge and Termination Due to Health and Safety

Revision 18-2; Effective September 3, 2018

 

Any member residing in the adult foster care (AFC) home provider’s residence, whose medical condition or behavior or mental health threatens the health and/or safety of him or her or others, is subject to discharge without notice from the AFC home.

The AFC home provider must take appropriate action if the member's medical condition deteriorates and requires more skilled intervention to ensure the member’s health and safety. Depending on the member's condition, appropriate action could include calling emergency medical services, the member's physician or the managed care organization (MCO) service coordinator working with the member or MCO-contracted AFC provider agency, as applicable. The AFC home provider must take action and must inform the MCO on the same day the AFC home provider becomes aware of the need to respond to a change in the member's medical condition.

The MCO must work with the AFC home provider or with providers of other services to arrange alternate services to meet the member's needs.

When the member's behavior causes the member to threaten the health and safety of him or her or others, the AFC home provider must take appropriate action which may include calling the police or sheriff's department, the member's physician, and does include the MCO service coordinator or MCO-contracted AFC provider agency, as applicable. The member must be removed from the AFC home as soon as possible if the member becomes a threat to the health or safety of him or her or others. In some instances, the MCO may call Adult Protective Services (APS) if hospitalization for psychiatric observation seems warranted.

The MCO must issue an Adverse Determination letter to the member within three days of receiving information regarding an incident which warranted the involuntary removal of the member from the AFC home. The effective date on the Adverse Determination letter is the date the form is dated and mailed/given to the member, even if the decision is appealed. Though the member may not be denied all services through the STAR+PLUS Home and Community Based Services (HCBS) program, the member has a right to appeal the decision of removal from the AFC home.

The member may not remain in the STAR+PLUS HCBS program AFC home during the appeal process. The MCO must work with APS or providers of other STAR+PLUS HCBS program services to arrange alternate placement for the member.

In circumstances in which the AFC home provider has moved in with the AFC member into the member’s home, the AFC member has the right to request termination of the arrangement at any time by contacting the MCO or MCO-contracted AFC provider, and request assistance with eviction of the AFC home provider. The MCO must ensure other STAR+PLUS HCBS program service options are offered should the AFC arrangement terminate.

 

7180 Annual Reassessment of the AFC Member

Revision 19-1; Effective June 3, 2019

 

In addition to the regular reassessment for the STAR+PLUS Home and Community Based Services (HCBS) program, which includes the managed care organization (MCO) registered nurse (RN) service coordinator completing the Medical Necessity and Level of Care, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums, and the individual service planning (ISP) documents, the MCO or MCO-contracted adult foster care (AFC) provider agency must also continue to meet all eligibility requirements and complete Form 2327, Individual/Member and Provider Agreement.

 

7200 Assisted Living Services

Revision 18-2; Effective September 3, 2018

 

 

 

7210 Introduction

Revision 19-1; Effective June 3, 2019

 

This section applies to the STAR+PLUS Home and Community Based Services (HCBS) program. Assisted living (AL) services provide a 24-hour living arrangement for persons who, because of physical or mental limitation, are unable to continue independent functioning in their own homes. Services are provided in personal care facilities licensed by the Texas Health and Human Services Commission (HHSC). STAR+PLUS HCBS program members are responsible for their room and board costs and, if applicable, copayment for AL.

The purpose of AL services is to promote the availability of appropriate services for elderly and disabled persons in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of the individual. The personal care facility must provide each individual a separate living unit to guarantee their privacy, dignity and independence.

 

7211 Housing Options in Licensed Personal Care Facilities

Revision 19-1; Effective June 3, 2019

 

The assisted living (AL) apartment may be an efficiency or one or two bedroom apartment, and each apartment must have a private bath and cooking facilities. An AL non-apartment setting is defined as a licensed personal care facility which has living units that do not meet the definition of an AL apartment, may be double occupancy, and must be:

  • freestanding; and
  • licensed for 16 or fewer beds.

STAR+PLUS Home and Community Based Services (HCBS) program AL contracts specify whether the facility has contracted to provide services under the housing options of AL or AL Non-Apartment. The provider may not deliver STAR+PLUS HCBS program services in a housing option for which the provider does not have a contract to deliver services. If a provider wishes to maintain both AL (single occupancy) and AL apartments (double occupancy) in one facility, the member’s contract must specify that information.

If the AL provider wishes to limit the types of apartments in the facility available to STAR+PLUS HCBS program members, the provider must specify these limitations in the contract, either at the time of signature or by amendment. The apartments in question must meet all qualifications as specified in this section. If there are no such specifications in the contract, all types of apartments in the facility must be available to STAR+PLUS HCBS program members.

If the provider limits the type of apartment available for STAR+PLUS HCBS program members and there is no apartment of that size available, they can refuse to accept any STAR+PLUS HCBS program member, based on not having space available. This would apply both for a member wanting to move into the facility from the outside, or to a private pay member currently in the facility who is becoming a STAR+PLUS HCBS program member. The member would then have the option of reviewing other available AL facilities (ALFs) in the area or adult foster care (AFC) homes.

"Freestanding" is defined as not physically connected to a licensed nursing facility, hospital or another licensed personal care facility, unless the total licensed capacity of both personal care facilities does not exceed 16 beds. At minimum, a covered walkway between buildings is required for physical connection.

At the member's request, portable kitchen units may be removed from the living area.

 

7211.1 Single Occupancy Apartments

Revision 19-1; Effective June 3, 2019

An assisted living (AL) apartment setting is defined as an apartment for single occupancy that is a private space with individual living and sleeping areas, a kitchen, bathroom and adequate storage space, as specified in the following:

  • The apartment must have a minimum of 220 square feet, not including the bathroom. Apartments in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.
  • The kitchen is an area equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.
  • The bathroom must be a separate room in the individual's living area with a toilet, sink and an accessible bath.
  • The bedroom must be single occupancy except when double occupancy is requested by the member.

 

7211.2 Double Occupancy Apartments

Revision 18-2; Effective September 3, 2018

 

An assisted living (AL) apartment must be a double occupancy apartment with a connected bedroom, kitchen and bathroom area that provides a minimum of 350 square feet of space per participant, and meet the following specifications:

  • Indoor common areas used by STAR+PLUS Home and Community Based Services (HCBS) program members may be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.
  • The kitchen must be equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.

 

7220 Description of Services

Revision 19-1; Effective June 3, 2019

 

The assisted living facility (ALF) must provide 24-hour care in a personal care facility licensed by the Texas Health and Human Services Commission (HHSC). Services include, but are not limited to:

  • Home management — Assisting with activities related to housekeeping that are essential to the member's health and comfort, including changing bed linens, housecleaning, laundering, shopping, storing purchased items and washing dishes.
  • Transportation and escort — Providing and/or arranging for transportation to:
    • local community shopping areas where a member may purchase items to meet his or her personal needs;
    • recreational activities, field or community trips; and
    • the nearest available provider that can provide medical care which may include medical appointments, therapies and other medical care, unless arrangements are made to transport the member to the medical care provider of the member's choice. Licensure as a personal care facility requires the facility to provide soap and toilet tissue at all times for member use. Other personal items must be purchased by the member. STAR+PLUS Home and Community Based Services (HCBS) program members receiving assisted living (AL) are entitled to receive medical transportation services through Medicaid for Medicaid-covered medical appointments. The ALF personnel are responsible for scheduling the transportation according to medical transportation procedure. If the STAR+PLUS HCBS program member wishes to attend an activity outside the facility, which is not a group activity sponsored by the facility, the member is responsible for paying for his or her own transportation.
  • 24 - Hour supervision — Periodic checks or visits to a member during each eight-hour shift to ensure that the member is safe and well.
  • Meal services include:
    • planning, cooking and serving three meals per day that are essential to the member's health and well-being. The meals must:
      • be suitable in quantity and adequacy to attain and maintain nutritional requirements, including those of special needs members; and
      • supply 100% of the recommended daily dietary allowance for adults, as recommended by the United States Department of Agriculture (USDA);
    • providing special diets, as required by the member's service plan;
    • offering dietary counseling and nutrition education for the member;
    • assisting the member with his or her meals, if necessary, which includes food texture modification, including grinding meats and mashing vegetables for members having trouble chewing; and
    • food management, including assistance with spoon feeding in instances when the member is temporarily ill, bread buttering, and milk opening for members with hand deformities, paralysis or hand tremors.
  • Social and recreational activities include:
    • organizing activities that require group and member-initiated activities;
    • providing opportunities to interact with other people;
    • providing interaction, cultural enrichment, educational or recreational activities, and other social activities on site or in the community in a planned program to meet the social needs and interests of the members;
    • providing four scheduled social activities per week; and
    • posting a monthly social or recreational activity at least one week in advance.

Personal care tasks must be provided, as identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, identified on the individual service plan (ISP) and approved by the MCO. A registered nurse (RN) must perform the medication administration assessment.

The AL provider is responsible through its licensure requirements for providing the administration of medications, which is the direct administration of all medications, or the assistance with or supervision of medication. This includes injections, if needed. Only a licensed nurse can give injections. The personal care facility may provide more services for the member than are identified in the ISP, but not fewer services.

 

7221 Requirements Related to Assisted Living

Revision 19-1; Effective June 3, 2019

 

STAR+PLUS Home and Community Based Services (HCBS) program members who wish to reside in a personal care facility must reside in a licensed assisted living facility (ALF) facility which is contracted with the managed care organization (MCO) to provide STAR+PLUS HCBS program services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services to four or more persons who are unrelated to the owner. The member is required to pay room and board, and possibly a copayment based on income in the assisted living (AL) setting. Refer to Section 3230, Financial Eligibility, for detailed information.

 

7222 Initial Responsibilities for Members Residing in ALFs

Revision 21-2; Effective August 1, 2021

 

The managed care organization (MCO) is responsible for helping the applicant or member select an assisted living facility (ALF) that can meet his or her needs. The MCO sends an authorization to the ALF that the applicant or member selects.

The ALF staff must explain the copayment requirement and room and board charges, described in Section 3236, Copayment and Room and Board, and Appendix VI, STAR+PLUS Inquiry Chart, to the applicant or member. Room and board must be paid by every STAR+PLUS Home and Community Based Services (HCBS) program ALF applicant or member. A copayment is not required of Supplemental Security Income (SSI) recipients. A copayment is required from those AL members whose financial eligibility was determined under the special institutional criteria. The MCO must:

  • determine the applicant's or member's room and board and copayment amounts, based on the Form H2065-D, Notification of Managed Care Program Services, received from Program Support Unit (PSU) staff, for the initial month of service and ongoing copayment amount for subsequent months;
  • document the amounts on Form H1700-1, Individual Service Plan;
  • verbally notify the applicant or member;
  • send a copy of Form H2065-D to the provider as notification of the amounts to be collected; and
  • assist the applicant or member and provider in resolving problems related to collection of the applicant's or member's copayment and room and board contributions.

Refer to Section 3236 for copayment and room and board guidance.

 

7223 Admission to an Assisted Living Facility

Revision 21-2; Effective August 1, 2021

 

Before admission, the managed care organization (MCO) faxes or mails to the assisted living facility (ALF):

The STAR+PLUS Home and Community Based Services (HCBS) program ALF provider is expected to provide to the new member a tour of the ALF, including staff and resident introductions. Members are encouraged to bring basic furnishings for bedroom areas with them.

In the event the member does not provide his or her own furnishings, the facility must provide for each member:

  • a bed with mattress;
  • chair;
  • table or dresser;
  • drawer space; and
  • enclosed closet space for clothing and personal belongings.

Furnishings provided by the ALF must be maintained in good repair.

 

7224 Personal Care 3

Revision 21-2; Effective August 1, 2021

 

STAR+PLUS Home and Community Based Services (HCBS) program applicants or members with heavy personal care needs who choose to reside in assisted living (AL) non-apartment settings may be approved for Personal Care 3 level services. Classification of a STAR+PLUS HCBS program applicant or member at the Personal Care 3 level is based on the applicant or member's assessed needs, as evidenced by a value of two or greater in one or more of the activities of daily living (ADLs) of transferring, eating or toileting, as assessed on the Medical Necessity and Level of Care (MN/LOC) Assessment, Section G, Physical Functioning and Structural Problems, Column A, Self-Performance.

During the initial pre-enrollment assessment and annual reassessment, the managed care organization (MCO) nurse completes the MN/LOC Assessment and uses the information recorded for transferring, eating or toileting to make a recommendation regarding the applicant's or member's need for the Personal Care 3 level. The recommendation is recorded on Form H1700-1, Individual Service Plan.

At the initial certification and each annual reassessment, the MCO must check Form H1700-1 to determine if the applicant or member who chooses to reside in an AL non-apartment setting is identified as meeting the Personal Care 3 level. If the provider nurse does not provide a recommendation for Personal Care 3 level, the MCO must contact the nurse to obtain a Personal Care 3 level. The MCO documents the nurse's recommendation in the case record. The MCO must inform the applicant or member that he or she meets the Personal Care 3 level, and ensure the applicant or member is aware of all facilities contracted to provide care at the Personal Care 3 level by presenting a choice list of AL facilities that specifically identifies the Personal Care 3 facilities. The MCO authorizes the Personal Care 3 reimbursement rate if the applicant or member meets the Personal Care 3 level and chooses to reside in a contracted Personal Care 3 facility.

Changes may occur in a STAR+PLUS HCBS program member's health during the individual service plan (ISP) year that may cause the member to require a greater level of care in an AL facility (ALF), or move to an AL setting from a community setting. The MCO must review the most current MN/LOC Assessment to determine the provider clinician's recommendation regarding the member's Personal Care 3 level and ensure the member is presented with a choice of ALFs that are contracted at the Personal Care 3 level to provide a higher level of care.

Designation of an ALF as a Personal Care 3 facility is determined in the contracting process. To qualify as a Personal Care 3 facility, the ALF must meet the following requirements:

  • be a personal care facility licensed for four to 16 beds in a non-apartment setting;
  • provide 60 percent or more of its STAR+PLUS HCBS program members with a single occupancy bedroom;
  • maintain a minimum staffing ratio of one direct care staff member for every four members during the day and evening shifts, and a minimum of one direct care staff member for every eight members during the night shift; and
  • at least 60 percent of the total members served each month must require a minimum of one-to-one staff assistance as evidenced by a value of three or greater in one or more of the ADLs of transferring, eating or toileting, as assessed on the MN/LOC Assessment.

 

7230 Other Services Available to Members

Revision 19-1; Effective June 3, 2019

 

Each of the following services are provided according to the needs of the member, as authorized on the individual service plan (ISP), as a STAR+PLUS Home and Community Based Services (HCBS) program service and not included in the assisted living (AL) daily rate. The managed care organization (MCO) makes referrals for the services and coordinates delivery.

Adaptive Aids and Medical Supplies — The STAR+PLUS HCBS program AL member is eligible to receive needed adaptive aids and medical supplies under the STAR+PLUS HCBS program. Adaptive aids and medical supplies are defined as medical equipment and supplies that include devices, controls or appliances specified in the plan of care (POC) that enable members to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live. Refer to Section 6410, List of Adaptive Aids and Medical Supplies, for a list of adaptive aids and supplies that can be purchased through the STAR+PLUS HCBS program.

Minor Home Modifications (MHMs) — Services that assess the need, arrange for and provide modifications, and/or improvements to a member's residence to enable the member to reside in the community and ensure safety, security and accessibility. Minor home modifications are limited to those modifications identified and approved by the MCO on the ISP and apply to Type A facilities only. (Refer to Title 40, Texas Administrative Code §92.3, Types of Assisted Living Facilities.)

Occupational Therapy (OT) — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living, education, work, play, leisure and social participation. OT services consist of the full range of activities provided by a licensed occupational therapist or a licensed occupational therapy assistant (OTA), if under the direction of a licensed occupational therapist, within the scope of state licensure.

Physical Therapy (PT) — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. PT services consist of the full range of activities provided by a licensed physical therapist or a licensed physical therapy assistant (PTA), under the direction of a licensed physical therapist and within the scope of state licensure.

Speech Therapy (ST) — The evaluation and treatment of impairments, disorders or deficiencies related to a member's speech and language. Services include the full range of activities provided by licensed speech and language pathologists under the scope of the pathologist's state licensure.

Nursing Services — Services provided by a licensed registered nurse (RN) or licensed vocational nurse (LVN) within the scope of state licensure. Nursing services can be brought into the personal care facility for the member. If the projected cost of the member's services exceeds the annual cost limit, the MCO meets with the member to discuss the options for care, such as other living arrangements in adult foster care (AFC) or Title XIX Day Activity and Health Services. The member's choice for service delivery is given first priority as long as the cost for the service does not exceed the annual cost limit. STAR+PLUS services are also explored by the MCO for the delivery of all waiver services.

The use of self-administered oxygen is allowed in a STAR+PLUS HCBS program assisted living facility (ALF). Since oxygen is a flammable substance, precautions must be taken to ensure that smoking is prohibited in or around the area where the oxygen is being self-administered.

 

7240 Room and Board and Copayment Requirements

Revision 18-2; Effective September 3, 2018

 

The member must pay the required fees to be eligible for assisted living (AL) services. Refusal to pay the required fees can result in termination of services.

The facility must designate a due date for copayment and room and board in writing. The due date must be during the same month the copayment and room and board is applied. The facility must collect the entire copayment and room and board on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire copayment and room and board on or before the first business day thereafter.

 

7241 Room and Board Requirements

Revision 19-1; Effective June 3, 2019

 

All members must pay the room and board charges to be eligible for assisted living (AL). Room and board cannot be waived, but an assisted living facility (ALF) may choose to accept an applicant or member for a lower amount. STAR+PLUS Home and Community Based Services (HCBS) program policy does not direct the facility to accept or reject the applicant or member. The room and board charge is based on the Supplemental Security Income (SSI) federal benefit rate (FBR), minus a personal needs allowance of $85. This is a set rate unless there is a change in the FBR. Generally, the FBR only changes annually on January 1. The room and board charge is adjusted accordingly based on that change. For the initial month of entry, the monthly rate is divided by the number of days in that month, then multiplied by the number of days the member is in the ALF. The managed care organization (MCO) must notify the applicant or member of the initial amount of room and board to pay and the ongoing amount of room and board to pay.

 

7241.1 Copayment Requirements

Revision 19-1; Effective June 3, 2019

 

The amount of copayment the member is required to pay is determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialists through use of the MEPD copayment worksheet. MEPD specialists make the determination of the amount available. The managed care organization (MCO) communicates the amount of copayment each member is to pay the provider.

Program Support Unit (PSU) staff mail Form H2065-D, Notification of Managed Care Program Services, to the member and upload a copy of Form H2065-D to TxMedCentral. Once received through TxMedCentral, the MCO sends a copy to the assisted living facility (ALF), detailing the first month's copayment amount and the subsequent months' amounts.

 

7242 Personal Leave

Revision 18-2; Effective September 3, 2018

 

The member is entitled to 14 days of personal leave from the assisted living facility (ALF) each year. The member is responsible for the room and board charge and copayment for personal leave days.

A day of personal leave is defined as 24 continuous hours. STAR+PLUS Home and Community Based Services (HCBS) program assisted living (AL) members must sign out when leaving the facility and sign in upon returning. The sign-in log must have at minimum the following information:

  • name of the person;
  • time and date of departure;
  • destination;
  • emergency contact; and
  • type of leave (for example, personal leave or hospital leave).

 

7243 Nursing Services for AL Members

Revision 19-1; Effective June 3, 2019

 

If a member is residing in an assisted living facility (ALF), all of the administration of medications, including injections, are provided by the nurse. It is possible that a member residing in an ALF does not need any nursing tasks that are to be delivered by the STAR+PLUS Home and Community Based Services (HCBS) program. Examples of when this may occur include when the member's only nursing need is for medication administration that is provided by the nurse or when the member is receiving nursing services through Medicare.

 

7244 Response to AL Member Condition Change

Revision 19-1; Effective June 3, 2019

 

If the member experiences a change in health or conditions related to the amount and type of care the member requires, the managed care organization (MCO), in conjunction with the other members of the interdisciplinary team (IDT), the provider, and the member or authorized representative (AR) may explore other means to serve the member adequately in his or her current setting. The use of day activity and health services (DAHS) for daily nursing tasks or the direct provision of nursing by provider nurses may be explored as alternatives that would avoid disrupting the member's living arrangement. Nursing tasks cannot be delegated in assisted living facility (ALF) settings.

If a member exhibits behavior or degradation of mental health that threatens the health or safety of himself or herself or others, or the member's needs exceed the licensed capacity of the facility, the AL provider must take appropriate action and notify the MCO orally by the next business day. The provider must confirm the verbal report in writing within seven days. The MCO must take appropriate actions based on the oral notification to assess the member's continued eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program. Refer to Section 7251, Facility Reporting and Notification Requirements.

If a STAR+PLUS HCBS program member living in an assisted living (AL) apartment becomes a safety hazard to the member or others due to the member's operation of the stove or cooking unit in the apartment, the AL provider can disconnect the unit and must notify the MCO by the next business day. The MCO must investigate the situation and document any recent or previous incident which indicates a threat to the health or safety of the member or others. The MCO, in cooperation with the IDT, the AL provider, and the member's family or AR, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The decision is documented on Form H2067-MC, Managed Care Programs Communication, which is sent to the AL provider within three business days of the IDT meeting.

 

7245 Hospital and Nursing Facility Stays

Revision 19-1; Effective June 3, 2019

 

Hospital Stays

To reserve bed hold during hospital stays, the member must pay the daily room and board charge.

The facility's bed hold charge or the negotiated bed hold charge for reserving a member's space during hospital stays may not exceed the maximum amount established by the managed care organization (MCO).

The facility does not bill the MCO for days the member is hospitalized. The member's room and board charge, used as a bed hold charge, constitutes the entire payment to the facility when a member is hospitalized.

The facility must notify the MCO via Form H2067-MC, Managed Care Programs Communication, when the member has been in the hospital for 30 days. The MCO monitors the member's situation every month up to four months to determine if the stay will become permanent. If the member stays in the hospital longer than four months, the member is systemically disenrolled. The MCO must notify PSU via Form H2067-MC.

A hospital includes a rehabilitation hospital or a rehabilitation floor or wing of a medical hospital.

 

Nursing Facility Stays

For issues related to nursing facility (NF) payment, see the Medicaid for the Elderly and People with Disabilities Handbook, Section H-1700, Deduction for Home Maintenance.

The MCO must follow the Uniform Managed Care Contract (UMCC), Attachment B.1, Section 8.3.2.6, Nursing Facilities, related to NF stays.

 

7246 Termination Due to Failure to Pay the Required Contribution to the Cost of Care

Revision 19-1; Effective June 3, 2019

 

If the member or authorized representative (AR) fails to pay the entire copayment and room and board by the facility's due date, the facility must notify the member or AR and the managed care organization (MCO) in writing that payment was not received. The facility must make an oral notification no later than the first business day after the due date. The facility follows up in writing within five days of when the member or the AR fails to pay the required payments.

Upon receipt of the written notice, the MCO:

  • coordinates with the facility to convene a meeting of the interdisciplinary team (IDT) within five business days of receipt of the written notification. The IDT must include the member, a facility representative, the MCO and the AR, if applicable;
  • explores with the member and IDT if there are new circumstances preventing the member from making the required payment. Circumstances to consider are:
    • the member has a situation involving a mandatory recoupment or other changes in income requiring an adjustment in countable income;
    • circumstances indicate that the member is being exploited by another person; and
    • other situations exist in which the member and facility can work out an agreement for the member to pay the required payments;
  • makes every effort to resolve the problem with the member and the facility;
  • advises the member of the consequences that result from refusal to make the required payments to the assisted living facility (ALF), including:
    • termination of eligibility;
    • eviction; and
    • being placed at the end of the interest list if the member reapplies for services in the future; and
  • asks the member to read and sign Form 2119, Residential Care or Assisted Living Contribution Acknowledgement, if the situation cannot be resolved and the member continues to refuse to pay the required payments. The form states that the member refuses to pay the required payments and understands the consequences of not meeting this eligibility requirement. If the member refuses to sign, the MCO documents the refusal on Form 2119 and has a witness sign. The MCO leaves the member a copy of Form 2119 and retains the original copy with the signature in the member's case record. The MCO advises the member that he or she will receive a notice to terminate services. The MCO also advises the member that he or she will not be allowed to move to another ALF while the member has an outstanding balance at the current ALF, and the current ALF may evict the member for refusal to pay.

After the IDT meeting, the MCO must:

  • make any appropriate referrals to adjust countable income;
  • refer to Adult Protective Services (APS), if exploitation is suspected; or
  • coordinate the notice of termination with the facility and Program Support Unit (PSU) staff by sending Form H2067-MC, Managed Care Programs Communication, within five days of the IDT meeting.

If the situation cannot be resolved and the member refuses to pay for any reason, within three business days of the MCO's notification, PSU staff:

  • mail the member Form H2065-D giving the member notice that services will be terminated effective the end of the month following the end of the 30 day notification period, as indicated on Form H2065-D unless the member pays the required payments. In the comments section of Form H2067-MC, PSU staff advise the member that services will end and the facility may evict the member if payment is not made by date indicated on Form H2065-D;
  • send the facility a copy of Form H2065-D;
  • fax a copy of Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • upload a copy of Form H2065-D to TxMedCentral in the MCO's SPW folder, using the appropriate naming convention and a copy of Form H2065-D, following the instructions in Section 5110, TxMedCentral Naming Convention and File Maintenance; and
  • email a copy of Form H2065-D to the ERS mailbox for MAO members.

If the member does not appeal:

  • the facility may initiate eviction proceedings by giving the member an eviction notice in writing stating eviction will be effective the date indicated on the Form H2065-D.
  • and the member has not made other living arrangements by the denial date, the facility makes a referral to APS.
  • and the facility is in compliance with the provisions of its license and contract regarding the eviction of members, the facility evicts the member on the date provided on the written eviction notice.

If the member does appeal by the effective date of the action on Form H2065-D, PSU staff notify the MCO by uploading a copy of Form H2065-D to TxMedCentral in the MCO’s SPW folder. The member may receive other services, but remains ineligible for assisted living (AL) until all outstanding payments are made.

 

7250 Standards for Operation

Revision 21-2; Effective August 1, 2021

 

Assisted living facilities (ALFs) must:

  • provide each member the choice of a private or semi-private room;
  • reserve space for up to three days from the agreed-upon entry date for each referred member before requesting another referral;
  • designate a separate bedroom area for members in dual facilities where nursing facility (NF) members are co-housed in the facility; and
  • accept all managed care organization (MCO) referrals if space is available.

The only reason a STAR+PLUS Home and Community Based Services (HCBS) program assisted living (AL) provider could refuse to accept a referral is if the member's condition makes the member inappropriate for the facility according to the facility's personal care licensure.

Having a communicable disease does not necessarily make a member inappropriate for placement in an AL setting. Transmission of communicable diseases and conditions can be prevented through the implementation of infection control procedures, including universal precautions. Licensure standards for personal care facilities require facilities to have Infection Control Policy and Procedures, including universal precautions, in operation to safeguard employees and residents from these and other diseases, and contagious conditions. If transmission of the condition or disease cannot be controlled, the member cannot be placed in a STAR+PLUS HCBS program AL setting.

To receive AL services under the STAR+PLUS HCBS program, the applicant must first be determined eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists, where applicable, to complete the Medicaid eligibility determination.

The MCO discusses residential options with the member, allowing the member to choose his or her preference. If an ALF is chosen, a verbal referral is made to the provider as an alert that space is needed. The starting date for services is a negotiated date between the MCO, the member and the AL provider. The initial copayment amount is computed based on the starting date. Form H1700-1, Individual Service Plan, and applicable attachments are sent as follow-up, along with a copy of Form H2065-D, Notification of Managed Care Program Services, which authorizes the provider to deliver STAR+PLUS HCBS program services, and Form H2067-MC, Managed Care Programs Communication, confirming the negotiated service initiation date.

Note: Appropriate action must be taken if the facility finds that a member threatens the health and safety of himself or herself or others. If a stove or cooking unit needs to be disconnected, the MCO service coordinator, in cooperation with the interdisciplinary team (IDT), makes this decision. The IDT must also include the MCO, the AL provider and the member's family or authorized representative (AR), if any.

The AL provider can disconnect the stove or cooking unit if the member exhibits a behavior that threatens the health and safety of him or her or others. The ALF must inform the MCO service coordinator of the disconnection by the next business day after it occurs. The MCO investigates the situation and documents any recent or previous incidents that indicate a threat to the health or safety of the member or others. If the decision is made to approve a disconnection, the MCO service coordinator documents actions on Form H2067-MC that is sent to the AL provider within three days.

Note: The ALF must make oral notification no later than the first business day after the due date. Within five business days of the MCO receiving notification from the provider that the member has failed to pay the copayment or room and board, the MCO uploads Form H2067-MC to TxMedCentral in the XXXSPW folder using the appropriate naming convention. Form H2067-MC serves as notification to PSU staff of the member's failure to pay the copayment or room and board. Within three business days, PSU staff must send the member Form H2065-D stating services will be terminated if the member fails to pay the copayment and or room and board within 30 days of the date on Form H2065-D.

If a STAR+PLUS HCBS program member does not pay his or her copayment and/or room and board within 30 days of the date on Form H2065-D, the MCO contacts the member to learn the reason the fees were not paid. Even if there is a legitimate reason (such as the member's income check has not been received by the 10th day of the month) for the non-payment of the required fees, the member is still under obligation to pay the fees.

If the member simply refuses to pay the fees, or there is no legitimate reason for his or her failing to pay, the MCO writes a letter to the member, with copies to the facility manager and to the member's responsible party, if applicable, explaining the possible consequences of continued refusal to pay.

The MCO is responsible for working with the member during this time period to assure alternative services will be available. If the member refuses to leave the facility when his or her services are terminated, the facility must follow its written eviction procedures.

In addition, ALFs must:

  • conduct a health assessment with the member within three days of admission to the facility;
  • provide each member with training in the emergency or disaster procedures and evacuation plan within three days from the date of service initiation. The training must be documented in the member's record. The facility must also document all training and orientation provided to members and facility staff;
  • provide services according to the member's health assessment or individual service plan (ISP);
  • document the member's daily activity and service delivery on the daily census record;
  • obtain written approval from the MCO before discharging a member, except when MCO staff cannot be reached and the member threatens the health or safety of himself or herself or others;
  • help the member to prepare for transfer or discharge;
  • provide a minimum of four social and recreational activities per week;
  • collect payment from the member according to copayment and room and board policies. If payment is not made by the 10th day of the month, the facility must send notice to the member by the 11th day of the same month;
  • allow the member to manage his or her finances and/or trust funds. The facility must provide assistance to the member in managing his or her finances only if the member requests assistance in writing;
  • refund, within five business days after the member has been discharged, the full balance of the member's personal funds that the facility deposited in an account. This applies to copayments and trust funds; and
  • inform the member verbally and in writing, before or at the time of admission, of bed hold policies for hospital or nursing facility (NF) stays, personal leave, eviction procedures, all available services in the facility, and charges for services not paid by the MCO and/or not included in the facility's basic daily rate.

Examples of charges not paid by the MCO could be the destruction of facility property or any additional charges, such as pet deposits. Items not required to be provided by the AL provider through the ALF licensing standards (for example, returned check fees, service deposits) may be charged to the member if listed in the admission agreement. The MCO may contact Texas Health and Human Services Commission (HHSC) Regulatory Services Division regarding any questionable items charged to the member.

 

7251 Facility Reporting and Notification Requirements

Revision 19-1; Effective June 3, 2019

 

The facility must verbally report to the managed care organization (MCO) the following occurrences pertinent to member services by the next business day after they occur. These occurrences must be followed up in writing within five business days after they occur and may lead to MCO intervention and/or termination of services, including but not limited to:

  • significant changes in the member's health and/or condition, such as:
    • the member enters a hospital, nursing facility (NF), state school or state hospital;
    • death of a member; or
    • serious occurrences or emergencies involving the member or facility staff; and
  • changes based on member actions, such as the member:
    • is discharged because he or she threatens the health or safety of himself or herself or others;
    • leaves the state;
    • requests that services end;
    • refuses to comply with the individual service plan (ISP);
    • fails to pay the copayment;
    • exceeds personal leave days; and
    • requests to move to another facility.

If a member exhibits behavior that threatens the health or safety of himself or herself or others, or the member’s needs exceed the licensed capability of the facility, the provider's written notice must explain the situation and the reasons the member is no longer appropriate for the services. With the concurrence of the MCO, discharge can be as soon as practical when:

  • the health or safety of individuals in the facility would be endangered if the member would remain in the facility; or
  • the member's medical needs escalate beyond the capability of the facility to meet the member's needs. For example, the member's mental condition may deteriorate to the point that involuntary commitment to a mental institution is necessary.

 

7252 Member Documentation

Revision 18-2; Effective September 3, 2018

 

The facility must maintain records for each member that include at least the following information:

  • health assessment;
  • serious occurrences or emergencies involving members or facility staff;
  • incidents when a member threatens the health or safety of himself or herself or other residents in the facility;
  • documentation when the member has used 10 personal leave days during the member's current individual service plan effective period;
  • documentation when the member's needs exceed the licensed capability of the personal care facility;
  • termination of services to a member;
  • hospitalization of a member;
  • death of a member; and
  • documentation when a member requests to move to another facility.

 

7260 Staffing and Training Requirements

Revision 18-2; Effective September 3, 2018

 

The facility must provide all staff with training in the fire, disaster and evacuation procedures within three business days of employment. The training must be documented in the facility records.

 

7270 Copayment and Trust Fund Records

Revision 18-2; Effective September 3, 2018

 

 

 

7271 Copayment

Revision 11-3; Effective September 1, 2011

 

The facility must keep receipts for all copayments collected. The facility must deduct the copayment amount as documented on Form H2065-D, Notification of Managed Care Program Services.

The facility must maintain a current member copayment ledger system that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances; it must be maintained in accordance with generally accepted accounting principles. If a member copayment is paid from a trust fund, the facility still must prepare a receipt.

The ledger must also reflect room and board charges and payments, and the member must be given a receipt for the room and board payments.

 

7272 Trust Fund Records and Written Receipts

Revision 19-1; Effective June 3, 2019

 

The facility must maintain trust fund records based on recognized fiscal and accounting principles, and have written permission from the member to handle his or her personal financial affairs.

Members must be informed that:

  • funds will be commingled with the funds of other members if the facility will handle the member's trust fund; and
  • the facility may review trust fund records of all members whose funds are commingled.

If the member is unable to sign or initial the transaction, or if the member signs his or her name with a mark (x), the transaction must be signed by a witness. The facility must:

  • keep the member's trust fund accounts separate from the facility's operating accounts. The separate account must be identified "Trustee, (name of facility), Member's Trust Fund Account";
  • make the member's trust records available for review by the facility during work hours without prior notice;
  • not charge the member for services that the facility is expected to provide for the member;
  • refrain from charging the member for banking service costs if the member's trust fund is in a pooled account;
  • obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the facility is handling; and
  • include at least the following in the trust fund records:
    • member's name;
    • identification of member's representative payee or responsible party;
    • transactions; and
    • member's earned interest.

The facility may choose one of the following options:

  • records of the date and amount of each deposit and withdrawal;
  • the name of the person who accepted the withdrawn funds; and
  • the balance after each transaction.

Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his or her trust fund, the transaction or receipt must be signed by a witness or signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his or her name, a witness must sign the transaction or receipt.

  • distribute the interest earned on any pooled interest banking account in one of the following options:
    • prorated to each member on an actual interest earned basis;
    • prorated to each member on the basis of his or her end-of-quarter balance; or
    • prorated to each member's account monthly if interest is paid on a monthly basis.

If the facility earns interest on any pooled interest account, the interest earned must be prorated to each member's account. Deposit entries should be documented as "interest" in the member's ledger. All transactions must be posted by the middle of the following month. The facility may:

  • keep a running balance; or
  • compute a balance at the end of the month.

If the facility maintains a trust fund, the facility staff must:

  • give the member a receipt for the money deposited into the trust fund;
  • deposit the member's monthly income into the account; and
  • write a check for the copayment and the room and board payment out of the trust fund account into the facility operating account.

Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account. If the member writes a check to be deposited into his or her trust fund account and there are insufficient funds to cover the check, the facility can charge the member only the actual insufficient funds fee charged by the bank.

There is no requirement that the deposit into the trust fund be made on the same date the money is received. However, the facility must ensure that the deposit slip/bank statement reflects the same amount recorded on the receipt.

 

7273 Records and Receipts

Revision 18-2; Effective September 3, 2018

 

The facility must ensure that records include written receipts for all purchases made by or for members. A receipt is a written or computer-generated, signed record of payment prepared at the time of payment. If the payment is in person, the written or computer-generated receipt must be signed and contemporaneous with the payment. If the payment is by mail, a statement at the end of the month satisfies the requirement for a written receipt and a bill for the next month. If a single receipt is written for different items, the receipt must clearly describe what the receipt covers.

The record or receipt must include the:

  • name of member;
  • date the money was received;
  • coverage period;
  • purpose of payment;
  • amount received;
  • source of the money;
  • amount returned, if any; and
  • signature of the facility representative.

The facility is required to have both a trust fund ledger and a copayment ledger. A current member copayment ledger system must be maintained that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances, and be maintained in accordance with generally accepted accounting principles.

The facility must maintain both receipts for monies received from members and bank deposit slips showing the money deposited. These amounts must correspond to amounts recorded in the member's trust fund ledger. This system must be maintained in accordance with generally accepted accounting principles.

Vendor withdrawal records must be maintained, regardless of how facility staff account for trust fund transactions (withdrawals on a ledger, cash envelope or individual checkbook register). They must retain receipts for any payment out of a trust fund account that is more than $1.00. The receipt, cash register tape or sales statement is documentation of who actually received the money that was withdrawn from the trust fund account, and that the money was spent as authorized. Any unused money returned to the trust fund custodian must be redeposited to the member's trust fund account and appropriately documented. The prerequisites that allow withdrawal from the member's trust fund are:

  • the purchase must be authorized by and for the benefit of the member;
  • the cost must be reasonable; and
  • facility staff do not profit from the transaction. For example, purchasing items in bulk and selling them at a higher price; or the member authorized the purchase of a TV, stereo, refrigerator, and staff are using it.

 

7274 Vendor Receipts

Revision 11-3; Effective September 1, 2011

 

The following information must be included on all trust fund vendor receipts (other than long-term payments):

  • name of the member;
  • date the receipt was written;
  • store name;
  • amount of money spent or received; and
  • item purchased.

 

7275 Group Purchases

Revision 18-2; Effective September 3, 2018

 

Often, a single purchase is made for goods to be distributed among specific members (for example, cigarettes). In such a case, the invoice or receipt should show the:

  • names of the members for whom the purchase was made; and
  • portion of the total price charged to each individual account.

Group purchases are only allowable if they can be traced to the member.

 

7276 Payment of Copayment and Room and Board from Trust Fund

Revision 18-2; Effective September 3, 2018

 

It is an acceptable and recommended practice to deposit the member's income into the trust fund account and then pay the copayment and room and board from the trust fund account. In this way, the member's monthly payments can be traced to the trust fund. When the copayment and room and board is paid from the trust fund account, the corresponding member's account receivable ledger must show proper credit to the member's account.

Long-term Payments

For long-term payments, facility staff must obtain a signed statement from the member or responsible party authorizing long-term payments on the member's behalf. Examples of long-term payments include insurance premiums, church tithe and cable TV. If the facility:

  • has a signed statement from the member authorizing the facility to pay long-term payments on the member's behalf, they do not need a monthly receipt from the vendor; or
  • does not obtain a signed statement from the member or authorized representative (AR) authorizing it to pay the monthly payment on the member's behalf, the facility must have a vendor receipt that includes all items previously identified.

Daily Withdrawals for Minor Purchases or Petty Cash Withdrawals

Members usually require small amounts of money to meet their daily needs for items such as soft drinks, snacks, etc. It is often difficult to keep supporting documents for all such minor purchases.

The member's signature or authorization for a cash withdrawal must be on the individual member ledger, the cash envelope or on a receipt.

Bulk Purchases

Bulk purchase of the same items may be made by the facility. In this case, the member's signature and the amount of the purchase must be on the member ledger or a receipt.

 

7277 Member Authorization

Revision 18-2; Effective September 3, 2018

 

If the member is unable to sign or initial the transaction, or if the member signs his or her name with a mark (X), the transaction must be signed by a witness. A witness is anyone other than the:

  • facility employee who is responsible for managing the trust fund accounts;
  • supervisor of the employee who manages the trust fund account; or
  • person who is receiving payment for services to the member.

 

7278 Refunds to Discharged or Deceased Members

Revision 18-2; Effective September 3, 2018

 

The facility must refund the full balance of the member's monies deposited in his or her trust fund account within five days after the member is discharged. If the member dies, there should be no payment from his or her trust fund account other than the refund to the responsible party. No funds may be dispensed to reimburse the facility for damages caused by the member to an assisted living (AL) apartment. If there is a responsible party, the facility may request voluntary reimbursement prior to the refund, but the responsible party is not obligated to agree.

Maintenance to the facility is included in the cost report as an allowance expense.

The two types of refunds are listed below:

Check — If the refund was made by check, the cancelled check or a copy of the receipt must be signed by the member or responsible party.

Cash — If the refund was made by cash, the receipt must be signed by the member or responsible party.

     

    7300 Respite Care

    Revision 19-1; Effective June 3, 2019

     

    Respite care services in the STAR+PLUS Home and Community Based Services (HCBS) program are available on an emergency or short-term basis to relieve those persons normally providing unpaid care for a STAR+PLUS HCBS program member unable to care for himself or herself.

     

    7310 Service Coordination Duties Related to Respite Care

    Revision 21-2; Effective August 1, 2021

     

    To be eligible for respite care services, the member must live in his or her own home or with relatives or other individuals. The member may not live in an adult foster care (AFC) or assisted living (AL) setting.

    The respite care provider must not be a primary caregiver, whether or not the respite care provider is related to the member, and must not live with the STAR+PLUS Home and Community Based Services (HCBS) program member for whom respite care is needed. If the member's primary caregiver is the paid attendant who also provides uncompensated care, in-home respite care may be provided only during those hours the primary caregiver would be providing uncompensated care to the member. If the primary caregiver is the paid attendant and will be absent during hours for which the primary caregiver is normally paid, it is the employer of record who has the obligation to provide a substitute attendant during this period.

    Respite care services is intended to relieve the primary caregiver during emergency or planned short-term periods. Respite care services must be authorized on the individual service plan (ISP) before it can be delivered. The respite care rate for out-of-home settings includes payment for room and board. There are no member copayment or room and board charges for respite care in out-of-home settings.

    The managed care organization (MCO) service coordinator is responsible for documenting the respite care services needed by the member. For example, a member needs respite care every Friday afternoon so the primary caregiver can attend class, or a member's primary caregiver has three four-day trips planned during the ISP year, or a caregiver has a history of emergency hospitalizations. The MCO service coordinator's documentation must also support that the member meets the eligibility criteria for respite care. The MCO service coordinator should provide supporting documentation regarding the number of hours requested or authorized when the 30-day maximum is requested or authorized. Respite care cannot be authorized retroactively. For STAR+PLUS HCBS program members who have an emergency need for respite care and respite care is not authorized on the ISP, the provider must contact the MCO for authorization prior to delivery of respite care services.

    The member must be given the opportunity to choose from the contracted providers that are appropriate considering the member's needs and the licensed capabilities of the provider. In-home respite care is provided by licensed providers contracting with the MCO and/or a Home and Community Support Services Agency (HCSSA) that is contracted with the MCO to provide services. Out-of-home respite care is provided by licensed nursing facilities, licensed personal care facilities and licensed AFC homes.

    The provider who delivers in-home respite care is responsible for providing the personal assistance services authorized on the ISP, with the possible exception of delegated nursing tasks. When a member is receiving in-home respite care and the attendant providing the personal care is not the same attendant to whom the nursing tasks were delegated, the nurse may directly provide the nursing care. It is necessary for the MCO to modify the ISP to include the increased direct nursing based on information provided by the provider. Other services (for example, physical therapy or minor home modifications) may continue to be delivered at the same time as the in-home respite care.

    Respite care services must be authorized on Form H1700-1, Individual Service Plan. Respite care services can be authorized as often as needed for primary caregiver relief or emergency absences of the primary caregiver up to the 30-day maximum per ISP year, within the limit of the member's cost limit. For example, if two hours of respite care are to be used per week, the ISP authorization is for eight 15-minute units. The calculation is two hours per week times 52 weeks = 104 hours multiplied by four 15-minute units. The annual limit on respite care services is 30 days, equivalent to 720 hours which equals 2,880 units (30 days times 24 hours per day; 720 hours = 2880 15-minute increments), unless approval to exceed the 30-day limit is given by the MCO. The MCO, who has overall responsibility for the coordination of STAR+PLUS HCBS program services, must keep track of the units a member has used. The provider may use Form H2067-MC, Managed Care Programs Communication, to notify the MCO of the dates and duration of respite care services delivered. The MCO can track the number of respite care days used.

     

    7311 MCO Approval to Exceed the Respite Service Cap

    Revision 19-1; Effective June 3, 2019

     

    To request approval to exceed the annual individual service plan (ISP) 30-day limit on respite care services, the provider must send a written request to the managed care organization (MCO) documenting the:

    • need for additional respite care units;
    • number of additional units needed;
    • cost estimate considering the location(s) in which the respite care services will be delivered;
    • overall service plan is within the member's ISP cost limit; and
    • ISP is adequate and meets the individual's needs in the community.

    The provider includes his or her telephone number and address in the written request. The MCO provides written approval or disapproval of the request. In reviewing requests to exceed the respite care services limit, the MCO must consider the intent of respite care services to relieve the caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:

    • members whose primary caregivers become ill, hospitalized or have a family emergency;
    • extenuating circumstances that cause care to be required beyond routine or periodic respite care relief; or
    • a breakdown in member or family support, causing an increased risk of institutionalization because of the physical burden and emotional stress of providing continuous support and care to a dependent person.

     

    7320 In-Home Respite Care

    Revision 21-2; Effective August 1, 2021

     

    In-home respite care offers services provided by managed care organization (MCO) contracted providers, on a short-term basis, to members unable to care for themselves because of the absence or need of relief for their unpaid primary caregiver.

    In-home respite care is provided in the member's own home, as authorized on the member's Form H1700-1, Individual Service Plan, when the unpaid primary caregiver needs relief. The provider is responsible for providing the tasks authorized on the member's ISP and Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, during the time the member is receiving in-home respite care.

    The provider must document in the member's clinical record:

    • the in-home respite care services provider was given a briefing on the member's status, needs and preferences prior to delivering services; and
    • dates and duration of the services delivered.

    In-home respite care services helps prevent member and/or family support breakdown and the consequent institutionalization, which may result from the physical burden and emotional stress of providing continuous support and care to a dependent person.

    The in-home respite care services provider must deliver the personal assistance services (PAS). The MCO may allow the in-home respite care services provider's registered nurse (RN) the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home respite care services provider.

    In-home respite care services is not intended to be used when the primary caregiver needs to be out of the house for short periods of time (for example, to go to the pharmacy or grocery store to pick up medications or grocery items). The primary caregiver should be encouraged to be out of the house for brief respite care when the attendant is providing the PAS.

     

    7330 Out-of-Home Respite Services

    Revision 19-1; Effective June 3, 2019

     

    Out-of-home respite care services provide a 24-hour living arrangement in an adult foster care (AFC) home, a licensed personal care facility or a licensed nursing facility (NF) for persons who, because of the unavailability of their primary caregiver, have no one to meet their needs on a short-term basis. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living (ADLs), supervision, and the provision or arrangement of transportation.

    Nursing tasks may be directly provided by licensed nurses in out-of-home respite care services or may be delegated as determined by the professional judgment of the provider's registered nurse (RN), unless facility licensure prohibits delegation.

     

    7331 Member Eligibility

    Revision 19-1; Effective June 3, 2019

     

    The respite care services member must:

    • meet all eligibility criteria, as specified in Section 3200, Eligibility;
    • reside in his or her own home;
    • have a primary caregiver who needs relief either on an emergency or planned short-term basis; and
    • not reside in adult foster care (AFC) or a personal care facility.

    The applicant for STAR+PLUS Home and Community Based Services (HCBS) program respite care services must complete the same eligibility determination process as other STAR+PLUS HCBS program members.

     

    7332 Provider Qualifications

    Revision 19-1; Effective June 3, 2019

     

    Out-of-home respite care services providers must be a:

    • licensed nursing facility (NF);
    • licensed personal care facility; or
    • Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home.

    In order to deliver STAR+PLUS Home and Community Based Services (HCBS) program out-of-home respite care services, the provider must complete and sign a contract with the managed care organization (MCO). The contract must be signed by both the provider and MCO prior to the provider serving members.

     

    7333 Description of Services

    Revision 19-1; Effective June 3, 2019

     

    The STAR+PLUS Home and Community Based Services (HCBS) program member may receive out-of-home respite care services in a nursing facility (NF), a personal care facility or a Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home, with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements. The STAR+PLUS HCBS program member may take any adaptive aids he or she is using to the out-of-home respite care setting.

    The managed care organization (MCO) provides the out-of-home respite care provider with the assessments and ISP attachments pertinent to the services the member will receive while in the facility or home. The provider must deliver services as identified on the member's ISP attachments.

     

    7334 Respite Care Services in a Personal Care Facility or AFC Home

    Revision 19-1; Effective June 3, 2019

     

    The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a personal care facility or adult foster care (AFC) home may receive nursing services or therapy services from outside providers while residing in the respite care setting. The need for any service must be authorized on the individual service plan (ISP) before the member receives the service.

    The STAR+PLUS HCBS program member receiving respite care services in an AFC home must qualify for placement in the particular level of AFC home by meeting the specific criteria for that level of home.

    Nursing services provided in a Level I or Level II AFC home may be delegated, according to the professional judgment of the provider's registered nurse (RN). Personal care facility licensure prohibits delegation of nursing tasks. In assisted living (AL) out-of-home respite care settings, nursing services must be provided directly by licensed nurses.

     

    7335 Respite Care Services in a Nursing Facility

    Revision 19-1; Effective June 3, 2019

     

    The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a nursing facility (NF) may receive therapy services from outside providers. The member's need for any service must be authorized on the individual service plan (ISP) before receiving the service. The NF is responsible for providing the needed nursing services to the member.

     

    7340 Room and Board

    Revision 19-1; Effective June 3, 2019

     

    Room and board charges are not allowable charges to the STAR+PLUS Home and Community Based Services (HCBS) program member receiving out-of-home respite care services. Room and board charges are included in the rates for the respite care services.

     

    7400 Emergency Response Services

    Revision 18-2; Effective September 3, 2018

     

     

     

    7410 Introduction to ERS

    Revision 18-2; Effective September 3, 2018

     

    Emergency response services (ERS) are provided through an electronic monitoring system and are used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-days-a-week monitoring capability, helps to ensure the appropriate person or service provider responds to an alarm call from a member.

     

    7420 ERS Program Purpose

    Revision 18-2; Effective September 3, 2018

     

    The purpose of emergency response services(ERS) under the STAR+PLUS Home and Community Based Services (HCBS) program is to:

    • enable aged and disabled persons to maintain dignity, independence, individuality, privacy, choice and decision-making ability; and
    • prevent or reduce inappropriate institutional care by providing home-based care and other forms of less intensive care.

     

    7430 ERS Member Eligibility

    Revision 19-1; Effective June 3, 2019

     

    In order to be eligible for emergency response services (ERS) through the STAR+PLUS Home and Community Based Services (HCBS) program, a member must:

    • have been determined eligible for the STAR+PLUS HCBS program;
    • be mentally alert enough to operate the equipment properly, in the judgment of the managed care organization (MCO) service coordinator;
    • have a telephone with a private line, if the system requires a private line to function properly;
    • be willing to sign a release statement that allows the responder to make a forced entry into the member's home if he or she is asked to respond to an activated alarm call and has no other means of entering the home to respond; and
    • live in a place other than an assisted living facility (ALF) or adult foster care (AFC) setting, institution or any other setting where 24-hour supervision is available.

    Members eligible for Community First Choice (CFC) must receive ERS through CFC, not through the STAR+PLUS HCBS program.

    Program Support Unit (PSU) staff will not accept or approve an initial or reassessment ISP with a "From" date of January 1, 2016, or later that includes personal assistance services (PAS) or ERS for non-medical assistance only (MAO) STAR+PLUS HCBS program members.

    MCOs must uploaded Form H2067-MC, Managed Care Programs Communication, to TxMedCentral to notify PSU if a member is receiving both STAR+PLUS HCBS program and CFC services concurrently. This is required for all non-MAO STAR+PLUS HCBS program members who also receive CFC, regardless of whether the individual service plan (ISP) is manually uploaded or electronically submitted.

     

    7440 Referral and Selection of Providers

    Revision 19-1; Effective June 3, 2019

     

    If the member is considered eligible for emergency response services (ERS), the managed care organization (MCO) shares a contracted list of all ERS providers with the member, who selects a provider from the list. The member can request a provider change; however, the member must contact his or her MCO service coordinator to request the change.

    The MCO follows the procedures in Section 3600, Ongoing Service Coordination, and gives members an explanation of the service and requirements.

     

    7450 Duties Related to ERS

    Revision 19-1; Effective June 3, 2019

     

    If the member wants and appears to be in need of emergency response services (ERS), the managed care organization (MCO) service coordinator determines if the member meets the general criteria for participating in ERS, as described in Section 7430, Member Eligibility. The MCO may involve other members of the interdisciplinary team in the decision regarding the member's physical and mental ability to participate in the ERS program. ERS may be authorized through the STAR+PLUS Home and Community Based Services (HCBS) program when it appears the member may need the capability to notify a respondent of an emergency. ERS services are limited to those individuals who:

    • live alone;
    • are alone for significant parts of the day;
    • have no regular primary caregiver for extended periods of time and who would otherwise require extensive supervision; or
    • live with someone who is too incapacitated to call for help should the need arise.

    During the course of the services, the MCO and the provider have the joint responsibility of keeping each other informed of changes or problems.

     

    7460 Provider Duties

    Revision 19-1; Effective June 3, 2019

     

    Managed care organization (MCO) contracted providers' duties specific to emergency response services (ERS) are described in Texas Administrative Code, Part 1, Chapter 52, Subchapter D.

     

    7500 Home-Delivered Meals

    Revision 20-2; Effective October 1, 2020

     

     

     

    7510 Description

    Revision 20-2; Effective October 1, 2020

     

    The home-delivered meals benefit provides hot, nutritious meals that are delivered to the member's home. Meals provided by contracted agencies are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a baccalaureate degree with major studies in food and nutrition, dietetics or food service management.

     

    7520 Provider Responsibilities

    Revision 20-2; Effective October 1, 2020

     

    Providers contracted to provide home-delivered meals must comply with the requirements of Texas Administrative Code (TAC), Title 40, Part 1, Chapter 55, Contracting to Provide Home-Delivered Meals.

    Home-delivered meals are delivered to the member’s home as authorized by the managed care organization (MCO). The meal must be delivered directly to the member or responsible party. The MCO must require providers to ensure that the provider’s employee or volunteer delivering the meal report any member illnesses, potential threats to the member’s safety or observable changes in the member’s condition to the provider. The MCO must require the provider to notify the MCO orally within one business day and in writing within five business days from the report.

    If the member or responsible party is not home to accept the delivery of a meal, the provider must comply with 40 TAC § 55.27(e).

    The MCO must notify the provider prior to, or no later than, the day that meal services are suspended. The MCO must suspend services in any of the following situations:

    • The member enters an institution.
    • The member requests that services be suspended or terminated.
    • The member dies.
    • The MCO service coordinator directs the provider to suspend services.

    Unless the interruption is the result of one of the above situations, the MCO must require the provider to obtain the MCO service coordinator's approval for service interruptions of more than two consecutive days. When the member requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the MCO service coordinator.

     

    7520.1 Frozen or Shelf-Stable Meals

    Revision 20-2; Effective October 1, 2020

     

    A provider that contracts with the managed care organization (MCO) to provide home-delivered meals must agree to provide services:

    • for a specific number of service days, with a minimum of five meals per week; and
    • to all eligible members in the service area unless services are suspended or the provider is unable to provide a certain therapeutic medical diet.

    Providers of home-delivered meals must submit a waiver request to the MCO if the provider determines that delivery of frozen or shelf-stable meals is required for certain individuals within the provider’s contracted service area. Any waiver granted is effective for a period not to exceed one fiscal year. The provider must not implement the waiver for delivery of a hot meal five days a week before MCO approval of the waiver request.

     

    7600 Transition Assistance Services

    Revision 18-2; Effective September 3, 2018

     

     

     

    7610 Introduction

    Revision 18-2; Effective September 3, 2018

     

    Transition Assistance Services (TAS) is a STAR+PLUS Home and Community Based Services (HCBS) program service designed to assist Medicaid members who are transitioning from a nursing facility (NF). An NF resident discharged from the facility into a waiver program is eligible to receive up to $2,500 in TAS for assistance with setting up a household. TAS is available on a one-time only basis and is not available to residents moving from an NF who are approved for assisted living (AL) or adult foster care (AFC) services.

     

    7611 Service Description

    Revision 18-2; Effective September 3, 2018

     

    Transition Assistance Services (TAS) pays for non-recurring, set-up expenses for members transitioning from nursing facilities to a home in the community. TAS is a benefit to cover basic and essential household items. Allowable expenses are those necessary to enable the member to establish a basic household and may include:

    • payment of security deposits required to lease an apartment or home;
    • set-up fees or deposits to establish utility services for the home, including telephone, electricity, gas and water;
    • purchase of essential furnishings for the apartment or home, including table, chairs, window blinds, eating utensils, food preparation items and bath linens, cleaning supplies and toiletries;
    • payment of moving expenses required to move into or occupy the home or apartment; and
    • payment for services to ensure the health and safety of the member in the apartment or home, such as pest eradication, allergen control or a one-time cleaning before occupancy.

    TAS does not include relocation services and is not available to assist the applicant in locating a residence.

     

    7620 Procedures at the Initial Interview

    Revision 18-2; Effective September 3, 2018

     

    All STAR+PLUS Home and Community Based Services (HCBS) program applicants who are in a nursing facility (NF) must be advised of the availability of Transition Assistance Services (TAS) and screened for the potential need for services.

    Within 14 business days of learning of a request to move to the community, the managed care organization (MCO) service coordinator discusses the applicant's or member’s available living arrangements in the community and asks the applicant or member where he or she intends to live upon discharge from the NF.

    TAS may be considered when the applicant or member:

    • plans to rent an unfurnished apartment;
    • plans to rent an unfurnished house;
    • has a home, but all the utilities have been off while in the NF;
    • has a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
    • needs his or her belongings moved to the new residence.

    If these or any other situations exist in which the applicant could benefit from TAS services, continue with the screening for TAS.

     

    7630 Identification of Needed Items and Services

    Revision 19-1; Effective June 3, 2019

     

    The managed care organization (MCO) conducts the interview with the applicant or authorized representative (AR) to identify the applicant's needs and determine if other resources are available to meet the needs. The MCO service coordinator completes Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, by marking each identified need and writing a description of the exact need.

    Example: If the applicant needs a deposit made for electricity, the MCO enters the name and address of the utility company and the amount required.

    The applicant selects a TAS agency from the list of contracted agencies.

     

    7640 Items and Services Included Under TAS

    Revision 18-2; Effective September 3, 2018

     

    Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, is divided into three main categories: deposits, household needs and site preparation needs.

     

    7640.1 Deposits

    Revision 18-2; Effective September 3, 2018

     

    Deposits include security deposits for rental and utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's or member's name.

    Security deposits may be paid as long as the payment is specifically called a security deposit and not rent, the payment is for a one-time expense, and the amount of the payment is no more than the equivalent of two months rent. Transition Assistance Services (TAS) cannot pay for rent.

    TAS can be used to pay for arrears on previous utilities if the account is in the member's name and the member will not be able to get the utilities unless the previous balance is paid. TAS cannot pay the first month's payment on utilities.

    TAS can be used to pay for a telephone since it is a basic need, but minutes or services on the telephone are not allowable expenses.

    TAS cannot pay for any charges for upgraded services beyond the basic service.

    TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company has a policy that requires a minimal supply of fuel to be delivered during the initial or reconnection service call. TAS funds cannot be used to top off a tank with fuel when the member's home is connected and has a supply of butane or propane.

     

    7640.2 Household Needs

    Revision 19-1; Effective June 3, 2019

     

    Household needs include basic furniture or appliances. This includes bedroom furniture, living room furniture, kitchen furniture, refrigerator, stove, washer, dryer, cleaning supplies and toiletries, etc.

    An applicant or member may request a specific brand or type of appliance, furniture or other Transition Assistance Services (TAS) item as long as the applicant's or member's needs are met within the cost limit.

    TAS items may be placed in a home other than the applicant’s or member's only when furnishings are not available and are necessary for the applicant or member to transition to the community. TAS cannot pay for items that would only be used by the other person.

    If existing items are not usable and the lack of a usable basic or essential item creates a barrier keeping the individual from returning to the community, the item is considered a need.

     

    7640.3 Housewares

    Revision 18-2; Effective September 3, 2018

     

    Housewares can include pots, pans, dishes, silverware, cooking utensils, linens, towels, clock and other small items required for the household.

     

    7640.4 Small Appliances

    Revision 18-2; Effective September 3, 2018

     

    Small appliances include a microwave oven, electric can opener, coffee pot, toaster, etc.

     

    7640.5 Cleaning Supplies

    Revision 18-2; Effective September 3, 2018

     

    Cleaning supplies include a mop, broom, vacuum, brushes, soaps and cleaning agents.

     

    7640.6 Other Items Not Listed

    Revision 18-2; Effective September 3, 2018

     

    Any special requests from the applicant or member not covered in the general list that meet the criteria as basic essential items to move to the community may be considered.

     

    7641 Services and Items Not Included in Transition Assistance Services

    Revision 19-1; Effective June 3, 2019

     

    Transition Assistance Services (TAS) does not include any items or services that are included under STAR+PLUS Home and Community Based Services (HCBS) program services such as adaptive aids, minor home modifications (MHMs), medical supplies or medications.

    TAS does not include any recreational items or appliances, including televisions, VCR or DVD players, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

    TAS does not cover the cost of repairs or expansion on the member's dwelling. TAS is not used for remodeling or renovation, upgrading of existing items or purchase of non-essential items.

    TAS funds cannot be used for food. The managed care organization (MCO) may refer the individual to emergency Supplemental Nutrition Assistance Program (SNAP) or local food pantry resources.

    Room and board are not allowable TAS expenses.

    TAS does not pay for monthly rental or mortgage agreements or ongoing utility charges.

     

    7642 Site Preparation

    Revision 18-2; Effective September 3, 2018

     

    Site preparation can include the following services:

    • moving expenses, which include the cost of moving the applicant's or member’s items from another location, or delivery charges on large purchased items;
    • pest eradication, if the applicant's or member’s place of residence has been unattended and some type of extermination is needed;
    • allergen control, if the applicant's or member’s place of residence has been unattended or the applicant or member is moving into a place that poses a respiratory health problem; or
    • one-time cleaning, if the applicant's or member’s place of residence has been unattended or the applicant or member is moving into a private home or apartment where pre-move-in cleaning should not be expected (for example, a family friend has an empty house available, but cannot provide the cleaning).

    Transition Assistance Services cannot pay for septic systems.

     

    7650 Estimated Cost of Items and Services

    Revision 19-1; Effective June 3, 2019

     

    The managed care organization (MCO) service coordinator provides a description and estimated cost of each item identified as needed under each service category on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization. The actual cost of an item may be used, if known. The amounts, either actual or estimated, must be less than or equal to $2,500.

    The MCO service coordinator must be as specific as possible when describing what items are needed and the estimated cost. The description must include size, color, specific types or any other identifying information, as specified by the member, which will assist the TAS agency in meeting the member's needs.

     

    7651 Totaling the Estimated Cost and Authorization of Transition Assistance Services

    Revision 21-2; Effective August 1, 2021

     

    The managed care organization (MCO) service coordinator totals each section of Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, and enters the amounts in the totals section to arrive at the final amount to be authorized under the TAS program. The $2,500 total amount is not entered as a flat rate.

    The applicant or member must sign the form stating that the items listed are the basic, essential needs required to move into the community, and he or she agrees that the TAS agency selected is authorized to make the purchases for him or her.

    The applicant or member selects a TAS agency from the list of contracted agencies.

    The MCO service coordinator must explain to the applicant that the service will not be authorized until the applicant is determined eligible for STAR+PLUS Home and Community Based Services (HCBS) program services, and notified in writing that he or she is eligible. The MCO service coordinator must contact the applicant or authorized representative (AR) before certification to verify the applicant has made arrangements for relocating to the community and has finalized a projected discharge date. The MCOs will code those items as delivered prior to the arrival date.

    The MCO service coordinator includes TAS on Form H1700-1, Individual Service Plan. The MCO service coordinator sends the applicant the notification of eligibility and sends the TAS agency Form 8604 and the authorization. The completion date on the authorization is two business days before the projected nursing facility (NF) discharge date. Allow at least five business days between the authorization date and the completion date. The TAS agency is expected to have all services and items completed by that date. For situations in which a shorter completion date is needed, the MCO service coordinator must contact the TAS agency and negotiate an earlier date. The MCOs will code those items as delivered prior to the arrival date.

    Additional applicant information to the TAS agency may be included on Form 8604 or Form H2067-MC, Managed Care Programs Communication. Form 8604 is mailed after the applicant or member is determined eligible for waiver services.

    The TAS agency may only obtain items or services for which the agency has received authorization on Form 8604. If the TAS agency identifies other items or services that the applicant or member may need, the TAS agency must obtain prior approval from the MCO. Refer to Section 7652 below.

     

    7652 Changes to the Authorization

    Revision 21-2; Effective August 1, 2021

     

    If the Transition Assistance Services (TAS) agency or the member identifies additional items required by the member after the TAS authorization has been sent, the TAS agency must obtain approval from the managed care organization (MCO) on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, prior to obtaining the item/service.

    The TAS agency must stay within the total dollar amount authorized on Form 8604. If the total amount of the items or services needed is more than the total amount authorized, the TAS agency must obtain prior approval and an updated Form 8604 from the MCO. The MCO service coordinator must update Form H1700-1, Individual Service Plan, to reflect the change in the amount for funds authorized.

    The MCO must send an amended Form 8604 updating the authorization to the TAS agency within two business days with the additional items and amounts authorized.

    MCO approval is required to authorize delivery of TAS services.

     

    7660 Transition Assistance Services Agency Responsibilities

    Revision 18-2; Effective September 3, 2018

     

    The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the forms carefully and contact the MCO if there are any questions regarding what has been authorized. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member, if necessary, to discuss the item in question. The MCO provides a revised TAS authorization form within two business days if it clarifies an item is authorized or approves a change to the authorization.

    The TAS agency purchases the authorized items or services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the dollar amount authorized by the MCO. The TAS agency contacts the member or authorized representative (AR), if necessary, to coordinate service delivery.

    The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

    The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or AR by the completion date to confirm that all authorized TAS services were delivered.

     

    7670 Three-Day Monitor Required

    Revision 10-0; Effective September 1, 2010

     

    The managed care organization (MCO) monitors the member within three business days after the discharge date to assure that all services and items authorized through the Transition Assistance Services (TAS) agency have been received. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the member’s case record.

     

    7680 Failure to Leave the Facility

    Revision 18-2; Effective September 3, 2018

     

    While the managed care organization (MCO) makes every effort to confirm that the member has definite plans to leave the facility, there may be situations in which the member changes his or her mind or has a change in his or her health making it impossible for the member to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

    The TAS agency must attempt to return any item(s) purchased on behalf of the member and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual.

    • If the TAS agency is unsuccessful in returning the item(s) for the amount of monies paid, or the deposits paid on behalf of the member cannot be recouped, the TAS agency is entitled to cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting individuals establish a home.
    • If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
    • If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the costs of the service, not to exceed the authorized amount.

    If the member is only in the community for a few days and returns to the nursing facility (NF), the member keeps the item(s) purchased through TAS.

     

    7690 Member Notifications and Appeals

    Revision 19-1; Effective June 3, 2019

     

    The purpose and limitations of Transition Assistance Services (TAS) must be explained to the applicant or member when determining the applicant's or member's needs. The applicant or member may appeal a decision regarding a needed item or service, but services should not be delayed due to the appeal.

    Form H2065-D, Notification of Managed Care Program Services, must be mailed by Program Support Unit (PSU) staff within two business days of eligibility determination advising the applicant or member of the date of eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program service before the authorization of any services. If the applicant or member has finalized the discharge plans, Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, may be sent to the TAS provider on the same day Form 8604, Transition Assistance Services (TAS) Assessment and Authorization, may be sent to the TAS provider on the same day Form H2065-D is sent to the applicant or member. If discharge plans are not finalized at the time of eligibility, Form 8604 may be sent at a later date by the managed care organization (MCO) to the TAS provider. PSU staff may address information on Form H2065-D in the comments section.

    The MCO notifies the applicant or member in writing of any changes in TAS services or items. The TAS provider is given provider authorization to deliver TAS services on Form 8604.

    Section 8000, Service Delivery Options

    Section 8000, Service Delivery Options Anonymous (not verified) Fri, 07/22/2016 - 09:30
    Body

    Revision 21-2; Effective August 1, 2021

     

    8100 Selection of a Service Delivery Option

    Revision 20-1; Effective March 16, 2020

     

    All managed care organization (MCO) service coordinators (SCs) must present service delivery options to the applicant, member or legally authorized representative (LAR) at the initial assessment and each subsequent annual reassessment. The service coordinator may use Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, Form 1581, Consumer Directed Services (CDS) Option Overview, and Form 1582, Consumer Directed Services Responsibilities, or a document created by the MCO and with Texas Health and Human Services Commission (HHSC) approval, to assist the applicant, member or LAR in making the service delivery decision.

     

    8110 Member Decision

    Revision 20-1; Effective March 16, 2020

     

    Managed care organizations (MCOs) must obtain a signature on Form 1584, Consumer Participation Choice, indicating the member's service delivery option choice. If, at any time during the year, a current member contacts the MCO requesting information on service delivery options, the MCO must present the information to the member.

    The MCO must keep Form 1584 in the member's case record and ensure the member or legally authorized representative (LAR) understands they may request a service delivery option change at any time by contacting the MCO.

     

    8200 Consumer Directed Services

    Revision 20-1; Effective March 16, 2020

     

     

     

    8210 Overview

    Revision 20-1; Effective March 16, 2020

     

    Consumer Directed Services (CDS) allows a member or their legally authorized representative (LAR) to hire and manage the people who provide their services within their current STAR+PLUS and STAR+PLUS Home and Community Based Services (HCBS) program. The philosophy behind CDS is that people are the best judges of the type and level of assistance they may need and how that assistance should be delivered.

    The CDS option was codified in Section 531.051 of the Government Code and expanded by the 79th Texas Legislature to provide more options for members to direct their long-term services and supports (LTSS). The rules for the CDS option are found in Texas Administrative Code, Title 40, Chapter 41.

    A member or LAR who chooses to participate in the CDS option becomes the CDS employer of their service providers and is referred to as the CDS employer. The CDS employer is required to select and use a financial management services agency (FMSA) to provide financial management services (FMS). FMS includes assistance to members to manage funds associated with services elected for self-direction. This includes initial CDS employer orientation and ongoing training related to the responsibilities of being a CDS employer. The FMSA conducts payroll files and pays employer federal and state taxes on behalf of CDS employers, screens potential service providers for employment eligibility and provides ongoing support for members who choose the CDS option.

    A member or LAR may choose the CDS option if:

    • the member's program offers the CDS option;
    • one or more program services in the member's authorized service plan are available for delivery through the CDS option;
    • the member or LAR agrees to perform, or to appoint a designated representative (DR) to perform, the CDS employer responsibilities required for participation in the CDS option;
    • the member or LAR selects a financial management services agency (FMSA) to provide financial management services (FMS); and
    • the member or LAR has developed and received approval from the service planning team for each required service back-up plan.

    If a member or LAR elects to participate in the CDS option, the member or LAR:

    • selects one FMSA to provide FMS;
    • with the assistance of the FMSA, budgets funds allocated in the member's authorized service plan for delivery through the CDS option; and
    • recruits, screens, hires, trains, manages and terminates service providers.

    As the CDS employer, a member or LAR may appoint in writing a willing adult as the designated representative (DR) to assist in performing employer responsibilities.

     

    8211 Consumer Directed Services Option Definitions

    Revision 20-1; Effective March 16, 2020

     

    The following words and terms, when used in reference to the Consumer Directed Services (CDS) option, have the following meanings.

    Actively involved — Involvement with a member that the member's service planning team deems to be of a quality nature based on the following:

    • observed interactions of the person with the member;
    • a history of advocating for the best interests of the member;
    • knowledge and sensitivity to the member's preferences, values and beliefs;
    • ability to communicate with the member; and
    • availability to the member for assistance or support when needed.

    Budget — A written projection of expenditures for each program service delivered through the CDS option.

    CDS employer — The member or LAR who chooses to participate in the CDS option and is responsible for recruiting, hiring, training, managing, retaining and terminating service providers to deliver program services.

    Designated representative (DR) — A willing adult appointed by the CDS employer to assist with or perform the employer's required responsibilities to the extent approved by the CDS employer. The DR is not the CDS employer. The DR must be a volunteer and cannot be a paid service provider.

    Employee — A person employed by the member or legally authorized representative (LAR) through a service agreement to deliver program services and is paid an hourly wage for those services.

    Employer support services — Services and items the CDS employer needs to perform. These are employer and employment responsibilities, such as office equipment and supplies, support consultation, expenses related to recruiting employees, and other items approved in Texas Administrative Code, Title 40, Part 1, Chapter 41, §41.507 and the Consumer Directed Services Handbook, Appendix XI, Allowable and Non-Allowable Expenditure.

    Financial management services (FMS) — Services delivered by the financial management services agency (FMSA) to the member or LAR, as described in Section 8214.2, FMSA Responsibilities. These services include orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member or LAR.

    Financial management services agency (FMSA) — An agency that contracts with a managed care organization (MCO) to provide FMS.

    Legally authorized representative (LAR) — A person authorized or required by law to act on behalf of a STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) member with regard to CDS, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult.

    Service backup plan — A documented plan to ensure that critical program services delivered through the CDS option are provided to a member when normal service delivery is interrupted or there is an emergency.

    Service Planning Team (SPT) — A group of people who meet to discuss the member’s needs, which consists of the member or LAR, the service coordinator and any other person invited by the member or LAR.

    Support advisor — An employee who provides support consultation to a CDS employer, a DR or a member receiving services through the CDS option.

    Support consultation — A service that provides skills training and assistance for performing CDS employer-related responsibilities.

     

    8212 Services Available in the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    STAR+PLUS services available in the Consumer Directed Services (CDS) option are:

    • Personal Assistance Services (PAS); and
    • Community First Choice (CFC) PAS or Habilitation.

    STAR+PLUS Home and Community Based Services (HCBS) program services available in the CDS option are:

    • In-home respite services;
    • Skilled nursing;
    • Employment assistance; 
    • Supported employment;
    • Physical therapy (PT);
    • Occupational therapy (OT); and
    • Cognitive rehabilitation therapy (CRT); and
    • Speech language therapy.

    A member or their legally authorized representative (LAR) may choose to self-direct any or all services available through the CDS option. The CDS option is available to members living in their own homes or the homes of family members. The CDS option is not available to members living in adult foster care (AFC) homes or assisted living facilities (ALFs).

    Choosing the CDS option does not impact a member's eligibility for services. Members can choose to have the above services delivered through the service delivery option of their choice. 

    Financial management services (FMS) is a required service in the CDS option. FMS provides assistance to CDS employers to manage funds associated with services elected for self-direction, and is provided by a financial management services agency (FMSA) contracted with the member’s managed care organization (MCO). This includes initial orientation and ongoing training related to CDS employer responsibilities and assisting with and approving the CDS employer’s budget. The FMSA also conducts payroll and pays employer taxes on behalf of the CDS employer. A monthly administrative fee is authorized on the individual service plan (ISP) and paid by the MCO to the FMSA for FMS.

    If requested, an FMSA can provide support consultation, which includes additional training and support for the CDS employer related to their employer responsibilities beyond the ongoing support provided by the FMSA. 

     

    8213 Advantages and Risks of the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    The member or legally authorized representative (LAR) should be informed of and consider the advantages and risks associated with the Consumer Directed Services (CDS) option before choosing to enroll. To assist the member in making an informed decision, the managed care organization (MCO) service coordinator must present information about service delivery options to the member or LAR. Refer to Section 8221, Presentation of the CDS Option.

     

    8213.1 Advantages of the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    Below are some of the advantages of using the Consumer Directed Services (CDS) option. The member or legally authorized representative (LAR):

    • has more control over who provides services and the days and times the services are delivered;
    • can offer benefits, such as bonuses, overtime pay, pay raises, vacation pay, sick pay and insurance to direct service providers, using funds from the CDS budget and in consultation with the financial management services agency (FMSA);
    • can control the final rate of pay for service providers within allowable limits;
    • may hire eligible service providers, such as family members, friends and other persons they know, in compliance with program and CDS rules;
    • will train service providers and supervise the services delivered by the service providers;
    • can appoint an eligible person as a designated representative (DR) to assist with or perform employer responsibilities; and
    • may use budgeted funds to hire a support advisor, if they need assistance beyond the support provided by the FMSA.

     

    8213.2 Risks and Liability Associated with the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    Below are some of the member responsibilities and potential risks associated with the Consumer Directed Services (CDS) option. The member or legally authorized representative (LAR) is:

    • responsible for locating attendants, back-up attendants and other direct service providers since there is no home and community support services agency (HCSSA) provider to fall back on to provide services. The member or LAR may contract with an HCSSA that agrees to provide back-up services, but the HCSSA is not required to contract with the member or LAR;
    • the CDS employer in the CDS option, and therefore assumes all liability related to employment. The member or LAR retains control over recruiting, hiring, training, managing and terminating employees. The persons providing services are not the employees of the financial management services agency (FMSA), the managed care organization (MCO), any state or federal agency, or other contracted provider agency. As the CDS employer, the member or LAR is solely responsible and liable for any negligent acts or omissions made by the employee(s), service providers or the designated representative (DR);
    • responsible for handling all conflicts with their employees. The CDS employer can request support consultation services be added to their service plan and budget to provide training and assistance with this employer responsibility, as necessary;
    • not able to decrease or increase the MCO-authorized service hours by adjusting the employee’s hourly wage;
    • required to keep certain paperwork to be specified by the FMSA for a required time period. The CDS employer must safely store the documentation for five years or longer;
    • ultimately responsible for payroll taxes owed to the Internal Revenue Service (IRS) and Texas Workforce Commission (TWC), and is liable if the FMSA fails to pay. The FMSA assumes full responsibility for payment of payroll taxes owed to the IRS; and
    • responsible for meeting all state and federal requirements as an employer and can be held liable for failure to meet those requirements.

     

    8214 Member and Financial Management Services Agency Responsibilities

    Revision 20-1; Effective March 16, 2020

     

     

     

    8214.1 Member Responsibilities

    Revision 20-1; Effective March 16, 2020

     

    The member or legally authorized representative (LAR) assumes responsibility as the employer of record.

    The member or LAR is responsible for:

    • recruiting, hiring, training, managing and terminating direct service providers;
    • setting wages and benefits for direct service providers within funds allocated for services elected for delivery through the Consumer Directed Services (CDS) option;
    • following state and federal laws including the payment of overtime;
    • evaluating each service provider's job performance;
    • approving, signing and submitting time sheets, invoices and receipts to the financial management services agency (FMSA) for payment to direct service providers;
    • providing the FMSA with necessary information to register as the member’s agent with the Internal Revenue Service (IRS) and the Texas Workforce Commission (TWC);
    • having the FMSA verify eligibility of each applicant before hiring or retaining for employment or service delivery;
    • resolving service provider concerns and complaints;
    • maintaining a personnel file on each service provider;
    • developing and implementing back-up service plans for services determined by the individual's planning team to be critical to the individual's health and safety; and
    • ensuring protection of the individual receiving services and preserving evidence in the event of a Department of Family and Protective Services Adult Protective Services investigation of an allegation of abuse, neglect, or exploitation against a CDS employee, designated representative, FMSA representative or service coordinator.

    The member or LAR must agree to accept financial management services (FMS) from the selected FMSA. The member or LAR must obtain an employer identification number from applicable government agencies and may request assistance from the FMSA to meet the requirements. The member or LAR must provide the information needed for the FMSA to register as the member's agent with the IRS and other appropriate government agencies.

     

    8214.2 FMSA Responsibilities

    Revision 20-1; Effective March 16, 2020

     

    A financial management services agency (FMSA) must provide financial management services (FMS) to a Consumer Directed Services (CDS) employer or designated representative (DR), including:

    • orienting and training the CDS employer or DR about CDS employer responsibilities for the Consumer Directed Services (CDS) option, including legal requirements of various governmental agencies;
    • assisting with and approving budgets for each service to be delivered through CDS;
    • with the CDS employer, completing forms required to obtain an employer identification number (EIN) from federal and state agencies;
    • conducting criminal history checks and registry checks of applicants;
    • verifying each applicant's eligibility with program requirements, including Medicaid fraud exclusions, before an applicant is employed or retained by the CDS employer;
    • registering as the employer-agent with the Internal Revenue Service (IRS) and assuming full liability for filing reports;
    • paying employer taxes on the CDS employer's behalf, to the IRS and Texas Workforce Commission (TWC);
    • receiving and processing employee time sheets, computing and paying all federal and state employment-related taxes and withholdings, and distributing payroll at least twice a month;
    • receiving and processing invoices and receipts for payment;
    • maintaining records of all expenses and reimbursements and monitoring budget;
    • submitting claims to the member's managed care organization (MCO);
    • providing written summaries and budgeting balances of payroll and other expenses at least quarterly;
    • preparing and filing employer-related tax and withholding forms and reports (this does not include filing personal income tax returns for employees); and
    • providing ongoing training and assistance, as needed or requested.

    The FMSA must obtain employer-agent status, as defined by IRS Rev. Proc., 2013-39,  and perform all responsibilities as required by the IRS and other appropriate government agencies. The FMSA enters into service agreements with each of the member's direct service providers before issuing payment.

    An FMSA may not provide financial management services (FMS) and case management services to the same member.

    The FMSA must participate in all mandatory training provided or authorized by the Texas Health and Human Services Commission.

    The MCO must monitor the FMSA’s performance and must ensure the FMSA performs all FMSA responsibilities, including participation in mandatory training.

     

    8220 Member Choice in the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    Information about the Consumer Directed Services (CDS) option must be presented to the STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) program member by the managed care organization (MCO) service coordinator at all initial and annual planning meetings or at any time requested by the member. The MCO service coordinator should provide written and verbal information about the benefits and requirements of the CDS option. The member chooses which services will be delivered through the CDS option and which will be through the agency or service responsibility option.

     

    8221 Presentation of the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    At the time of a member's enrollment in a STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) program that offers the Consumer Directed Services (CDS) option, and at least annually thereafter, the managed care organization (MCO) service coordinator or another person designated by the member's program must:

    • provide written materials on the CDS option to the member or legally authorized representative (LAR);
    • meet with and provide the member or LAR with an verbal explanation of the CDS option specific to the member's program;
    • present or make available to the member, the Texas Health and Human Services Commission (HHSC) video, The Consumer Directed Services Option, which can be accessed by visiting https://hhs.texas.gov/cds; and
    • complete Form 1581, Consumer Directed Services Option Overview.

    A member or LAR may request that an MCO service coordinator provide additional verbal and written information to the member or LAR regarding the CDS option or assist with enrollment in the CDS option at any time. The MCO service coordinator must comply within five business days after receipt of the request.

    A member or LAR who initially declines to participate in the CDS option when it is presented by their service coordinator may request information about CDS and elect to participate in the CDS option at any time while receiving services through STAR+PLUS or STAR+PLUS HCBS.

    The MCO service coordinator is responsible for presenting the CDS option annually to all new applicants and ongoing members who are not enrolled in the CDS option and whenever information is requested. The MCO service coordinator:

    • shares an overview of the benefits and responsibilities of the CDS option by reviewing Form 1581;
    • provides a copy of Form 1581 to the applicant or member or LAR; and
    • informs the applicant or member of the right to choose service delivery through the CDS option the agency option, or the service responsibility option (SRO).

    For initial applications, the MCO service coordinator obtains the applicant's signature on Form 1581 at the initial contact. The MCO service coordinator signs and dates the form verifying the information was presented to the applicant. A copy of Form 1581 is placed in the case record to document that CDS information was shared.

    For annual redeterminations, the MCO service coordinator provides the member or LAR with a copy of Form 1581 and clearly documents in the case record that Form 1581 was shared with the member.

    When members or LARs request information about the CDS option at other times, the MCO service coordinator must provide CDS information to the member within five business days after receipt of the request. The MCO service coordinator may provide the information by making a home visit or contacting the member or LAR by telephone. If a home visit is not made, the MCO service coordinator obtains the member's or LAR's signature by mailing Form 1581 to the member with a postage-paid and return envelope. The MCO service coordinator signs and dates Form 1581 indicating the information was presented. A copy of Form 1581 is placed in the member's case record to document Form 1581 was shared.

    The MCO service coordinator must discuss the CDS option, as well as differences in service delivery and payment options, and allow the member or LAR the opportunity to choose between delivery of services through the agency option or the CDS option.

    If the member or LAR is interested in participating in the CDS option once the information on Form 1581 is shared, the MCO service coordinator reviews Form 1582, Consumer Directed Services Responsibilities. The MCO service coordinator:

    • reviews with the member or LAR the responsibilities, risks and advantages of the CDS option;
    • assists the member or LAR as needed in completing the member self-assessment on Page 4 of Form 1582;
    • records the member's or LAR's choice to participate in the CDS option and assists the member in selecting and appointing a designated representative (DR), if needed, or records the choice not to participate in the CDS option;
    • obtains the DR's dated signature if the member or LAR chooses to appoint a DR; and
    • signs and dates Form 1582.

    If a member or LAR (the CDS employer) is not able to complete the Consumer Self-Assessment, a person appointed by the CDS employer to be the CDS employer's DR must be able to complete the Consumer Self-Assessment for the member receiving services to participate in the CDS option.

     

    8222 Member Choice and Enrollment in the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    A member or legally authorized representative (LAR) who decides to participate in the Consumer Directed Services (CDS) option must, with assistance from the managed care organization (MCO) service coordinator, complete the following forms:

    (1) Form 1582, Consumer Directed Services Responsibilities

    (2) Form 1583, Employee Qualification Requirements;

    (3) Form 1584, Consumer Participation Choice;

    (4) Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services through Consumer Directed Services, or Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing License for Certain Services Delivered through Consumer Directed Services, if required by the policies of the member's program; and

    (5) Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option, if the service is available in the member's program.

    A member or LAR who elects to participate in the CDS option must complete the self-assessment in Form 1582 and, if applicable, complete any assessment required by the member's program.

    A member or LAR who is not able to complete the self-assessment must appoint a designated representative (DR) to participate in the CDS option.

    The MCO service coordinator presents the information on Form 1582 and allows the member or LAR to choose between the CDS option or the Agency Option (AO). The MCO service coordinator develops the member’s service plan according to policy and CDS option rules.

     

    8222.1 Choosing the CDS Option and an FMSA

    Revision 20-1; Effective March 16, 2020

     

    If the member or legally authorized representative (LAR) chooses and is able to participate in the Consumer Directed Services (CDS) option, the MCO service coordinator proceeds to Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice. The MCO service coordinator:

    • provides Form 1583 information on the additional responsibilities of being an employer in the CDS option and who may or may not be hired in the CDS option;
    • shares Form 1584 indicating the applicant's, member's or LAR's selection of the CDS option;
    • obtains the applicant's, member's or LAR's dated signature on Form 1583 and Form 1584, if applicable;
    • signs and dates the forms; and
    • assists the member or LAR in choosing a financial management services agency (FMSA).

    The MCO service coordinator presents a list of MCO-contracted FMSAs and home and community support services agencies (HCSSA) providers. The member or LAR must select:

    • an FMSA to provide CDS financial management services (FMS); and
    • an HCSSA provider to deliver all other STAR+PLUS Home and Community Based Services (HCBS) program services that are not delivered under the CDS option.

    The MCO service coordinator develops the individual service plan (ISP) according to STAR+PLUS and STAR+PLUS HCBS program policy and CDS option rules.

     

    8222.2 Declining the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    If the member or legally authorized representative (LAR) declines the Consumer Directed Services (CDS) option after reviewing the self-assessment tool on Form 1582, Consumer Directed Services Responsibilities, the managed care organization (MCO) service coordinator:

    • obtains the applicant's, member's or LAR's signature on Form 1584, Consumer Participation Choice, indicating his or her selection of service delivery options; and
    • signs and dates Form 1584.

    The MCO service coordinator must ensure the member understands the CDS option is always available and that the member may call the MCO service coordinator to request a change to the CDS option at any time.

    Form 1584 is signed by the member any time a different service delivery option is chosen.

     

    8223 Designated Representative

    Revision 20-1; Effective March 16, 2020

     

    The member or legally authorized representative (LAR) has the option to appoint a designated representative (DR) to assist with the responsibilities of being a CDS employer in the Consumer Directed Services (CDS) option. If a CDS employer decides to appoint a DR, after the financial management services agency (FMSA) has been selected, then the FMSA assists the CDS employer in appointing a DR.  A CDS employer may appoint a willing adult as a DR to assist or to perform CDS employer responsibilities. The CDS employer maintains responsibility and accountability for decisions and actions taken by the DR. If the CDS employer chooses to appoint or change a DR, the CDS employer must complete Form 1720, Appointment of Designated Representative.

    The person appointed as the DR by the member or LAR must:

    • be willing to serve as the member's or LAR's DR for participation in the CDS option;
    • be or become actively involved with the member; and
    • complete the self-assessment in Form 1582, Consumer Directed Services Responsibilities, and any assessment required by the member's program.

    A DR must not:

    • sign or represent themselves as the CDS employer;
    • be paid to perform employer responsibilities;
    • be an employee of the CDS employer;
    • have a spouse employed by the CDS employer; or
    • provide a program service to the member.

    The CDS employer must notify the FMSA by fax or telephone within two business days after the appointment or change of a DR.

    • If the CDS employer notifies the FMSA by telephone, the CDS employer must fax or mail a copy of Form 1720 to the FMSA within five business days after the appointment or change of a DR.

    If a CDS Employer decides to revoke the appointment of a DR, the CDS employer must:

    • complete Form 1721, Revocation of Appointment of Designated Representative; and
    • provide a copy of the completed form to the DR, the FMSA and the individual’s case manager/service coordinator within two days after the effective date of the revocation.

    Based on documentation provided by the FMSA of a CDS employer's inability to meet employer responsibilities, the person-centered service planning team may recommend that the CDS employer designate a DR to assist with or to perform CDS employer responsibilities.

     

    8230 Developing the Individual Service Plan in the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    Service planning for a member who chooses to participate in the Consumer Directed Services (CDS) option is completed in accordance with the rules and requirements of the member's program in the same manner as if services are delivered through a program provider. Service planning includes:

    • determining the member's needs;
    • determining service levels;
    • justifying changes to the service plan;
    • maintaining costs and cost limits;
    • reviewing services; and
    • obtaining approval for planned services.

    The managed care organization (MCO) service coordinator must adhere to rules and requirements of the member's program if the member's services or a request for services is recommended for:

    • denial;
    • reduction;
    • suspension; or
    • termination.

    The MCO service coordinator must provide a written or verbal explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided verbally and in accordance with the member's program requirements.

    All STAR+PLUS and STAR+PLUS Home and Community Based Services (HCBS) program financial and non-financial eligibility requirements apply. All existing Medicaid eligibility requirements apply in the CDS option. CDS is not a service; it is a service delivery option. The MCO service coordinator completes all forms currently required for STAR+PLUS HCBS program services, including Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum, as applicable.

    The member using the CDS option must have a back-up plan to assure the provision of all authorized services critical to the member’s health and safety without a service break, even if there are unexpected changes in personnel. The CDS employer or designated representative (DR) must develop and receive approval from the MCO service coordinator for each required service back-up plan in order to participate in the CDS option. Refer to Section 8231, Service Back-Up Plans.

    The MCO service coordinator follows program policy when completing denials or terminations, reductions in services and suspensions. The MCO service coordinator must ensure the CDS employer fully understands the reasons for actions taken relating to the individual service plan (ISP) and STAR+PLUS or STAR+PLUS HCBS program services, as well as actions that could affect the member's participation in the CDS option.

    If the CDS employer or DR hires a nurse to provide services, nurses must operate within their license requirements outlined in the Texas Board of Nursing regulations (Texas Administrative Code, Title 22, Part 11), including registered nurse (RN) or physician oversight, plan of care development for nurses depending on the level of nurse hired, and RN or physician delegation, as indicated.

    In the CDS option, an RN must develop the nursing plan of care that determines hours of nursing needed and how many, if any, of the nursing hours can be provided by a licensed vocational nurse (LVN) and the same RN responsibilities listed in the paragraphs above. The RN and LVN must acknowledge nursing rules, including that an LVN must practice under the supervision of an RN, by completing Form 1747, Acknowledgement of Nursing Requirements.

    The RN may be employed through contract with a home health agency or private arrangement. The same expectation of collaboration exists between the MCO RN service coordinator and the RN that develops the plan of care in the CDS option.

     

    8231 Service Back-Up Plans

    Revision 20-1; Effective March 16, 2020

     
    The managed care organization (MCO) must discuss with the CDS employer or designated representative (DR) the services delivered through Consumer Directed Services (CDS) that are critical to the member's health and safety. The MCO must require the CDS employer or DR to develop a service back-up plan to ensure the health and safety of the member when regular service providers are not available to deliver services or in an emergency. The CDS employer or DR must develop a back-up plan and document the plan on Form 1740, Service Backup Plan, to assure the provision of all authorized personal assistance services without a service break.

    The CDS employer or DR, with the assistance of the MCO service coordinator (if needed), completes Form 1740. The service back-up plan must list the steps the CDS employer or DR will implement in the absence of the regular service provider. The service back-up plan may include the use of paid service providers, unpaid service providers, such as family members, friends or non-program services, or respite (if included in the ISP). The CDS employer or DR is responsible for implementation of the service back-up plan in the absence of the employee.

    Service back-up plans are submitted by the member, LAR or DR to the MCO service coordinator. The MCO service coordinator/service planning team (SPT), as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or SPT must approve each service back-up plan and any revision(s) before implementation by the CDS employer or DR. The MCO approves the service back-up plan by signing, dating and returning a copy of the plan to the CDS employer and DR, if applicable.

    The CDS employer or DR is required to:

    • budget sufficient funds in the CDS option budget to implement a service back-up plan;
    • review and revise each service back-up plan annually;
    • revise a service back-up plan if:
      • the member experiences a problem in the implementation; or
      • there are changes in availability of resources;
    • redistribute funds that are not used in carrying out a service back-up plan; and
    • provide a copy of the initial and revised service back-up plans and budgets to the financial management services agency (FMSA) within five business days after a plan's approval by the SPT.

    The FMSA must:

    • assist a CDS employer or DR, as requested, to revise budgets to meet service back-up plan strategies approved by the member's SPT;
    • review, validate and approve revised budgets in accordance with §41.511, Texas Administrative Code, relating to Budget Revisions and Approval;
    • reimburse documented, budgeted allowable expenses incurred related to implementing service back-up plan strategies; and
    • retain a copy of service back-up plans received from the CDS employer or DR.

     

    8232 Service Planning Team Responsibilities

    Revision 20-1; Effective March 16, 2020

    A member’s person-centered service planning team consists of persons required or allowed by the member's program. A Consumer Directed Services (CDS) employer must attend and participate in the member's service planning meetings. A CDS employer's designated representative (DR) may also attend the meeting with approval of the CDS employer.

    A CDS employer or DR must provide documentation related to services, service delivery, and participation in the CDS option when requested by a managed care organization (MCO) or MCO service coordinator.

    A CDS employer or DR must, when requesting a change in a service or the addition of a service for delivery through the CDS option, provide the person-centered service planning team (SPT) with documentation of circumstances that require a revision to the individual service plan (ISP).

    The MCO and STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) program SPT members make up the person-centered SPT for the member who selects the CDS option. The MCO convenes the SPT, as required by STAR+PLUS or STAR+PLUS HCBS program policy and obtains approvals, as appropriate, from SPT members. The MCO and SPT also assist in resolving issues and concerns related to the member's participation in the CDS option.

    The financial management services agency (FMSA) must send a quarterly expenditure report to the CDS employer and MCO service coordinator and document and notify the MCO of issues or concerns, including:

    • allegations of abuse, neglect, exploitation or fraud;
    • concerns about the member's health or safety;
    • non-delivery or extended breaks in services;
    • noncompliance with CDS employer responsibilities;
    • noncompliance with service back-up plans; or
    • over- or under-utilization of services or funds allocated in the ISP for delivery of services to the member through the CDS option and in accordance with the requirements of the STAR+PLUS or STAR+PLUS HCBS program.

    The member or legally authorized representative (LAR) is required to participate in the service planning meetings and provide requested documentation related to services and service delivery. The member or LAR must provide documentation to support any requests for a revision to the ISP.

    The FMSA may also participate in the member's service planning if requested by the member or LAR, and if agreed to by the FMSA.

    The FMSA must provide information related to the member's participation in the CDS option within three days of receiving a request for information from the member or LAR, DR, MCO or other involved parties.

    The MCO and SPT members, as appropriate, participate in approving back-up plans, developing corrective action plans, if necessary, and recommending suspension or termination of the CDS option. Refer to Section 8231, Service Back-Up Plans, and Section 8244, Corrective Action Plans.

     

    8233 CDS Employer Support Services in the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    A Consumer Directed Services (CDS) employer or designated representative (DR) may budget CDS employer support services and start-up expenses, through the services that are delivered by one or more employees in the CDS option. CDS employer support services include employment-related expenses, employer-related expenses and support consultation services. CDS employer support services exclude non-allowable expenditures listed in Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook.

    Start-up expenses must be:

    • budgeted for purchases projected before the delivery of services through the CDS option; and
    • accrued from the budgeted unit rate for services scheduled for delivery through the CDS option within the first three months of initiation of the CDS option.

    A CDS employer or DR may budget allowable, necessary, and reasonable employment-related services, goods or items, including:

    • recruiting expenses;
    • obtaining a criminal history report from the Texas Department of Public Safety;
    • purchasing employee job-specific training;
    • cardio-pulmonary resuscitation training;
    • first-aid training;
    • supplies required for an employee or provider of the service to perform a task, if not available through the member's program or other source and the purchase is allowable through the member's program;
    • non-taxable employee benefits; and
    • services, goods, and items specifically approved by the member's program as an employer support service or included as allowable expenditures in Appendix XI.

    A CDS employer or DR may budget employer-related services, goods or items required to meet CDS employer responsibilities, including:

    • basic office equipment, which may include a basic fax machine for the purpose of submitting documents to the financial management services agency (FMSA);
    • mailing costs;
    • expenses related to making copies;
    • file folders and envelopes; and
    • services, goods, and items specifically approved by the member's program as an employer support service or included as allowable expenditures in Appendix XI.

    Support consultation, if available through the member's program, is an optional service available to a member participating in the CDS option. Support consultation is delivered to a CDS employer, DR, or a member receiving services through the CDS option if that member will be the CDS employer within six months of the initiation of support consultation services to the member.

    Support consultation is provided by a person who meets the qualifications of a support advisor. A support advisor may be a contractor of the CDS employer or an employee or contractor of an FMSA.

    Support consultation must provide a level of training, assistance and support that does not duplicate or replace the services delivered by the FMSA, managed care organization (MCO) service coordinator, or other available program or non-program services or resources.

    Support consultation provides practical skills training and assistance to successfully manage service providers for authorized program services delivered through the CDS option. This includes skills training and assistance for:

    • recruiting, screening and hiring workers;
    • developing and documenting job descriptions;
    • verifying employment eligibility and qualifications;
    • completing documents required to:
      • employ an individual;
      • retain a contractor or vendor; and
      • manage service providers;
    • communicating effectively, solving problems and documenting CDS employer responsibilities in the CDS option;
    • developing, revising and implementing service back-up plans;
    • performing CDS employer responsibilities;
    • complying with the member's program and this section; and
    • developing ongoing decision-making skills for employer-related and employment-related situations.

    A CDS employer or DR may budget and initiate support consultation services while the member is participating in the CDS option. Before initiation of the service, the CDS employer or DR must:

    • identify the person or persons (the CDS employer, the DR or the member within six months after becoming the CDS employer) to receive the service and establish goals specific to the service;
    • obtain approval of the goals established for the service from the member's service planning team;
    • develop a budget for support consultation; and
    • obtain approval of the budget from the FMSA.

    If the member's service planning team authorizes support consultation, the team must:

    • approve the funds, the duration and the frequency of the service;
    • assist with development of goals and ensure that the activities required to meet the goals through support consultation comply with this section;
    • approve the goals for support consultation and the person or persons who will receive the service (the member, CDS employer or DR); and
    • terminate the service when goals are met.

    A CDS employer or DR may budget up to 10 percent of their CDS budget for CDS employer support services. A CDS employer or DR must not budget more than $600 annually or more than $50 per month for CDS employer support services if less than 12 months remain in the service plan.

     

    8240 Initiation of and Transition to the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    Within five business days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible member or legally authorized representative (LAR), or upon receipt of Form 1584 and within five business days after eligibility determination for an applicant applying for program services, a managed care organization (MCO) service coordinator must provide the following documentation to the financial management services agency (FMSA):

    • Form 1584;
    • the individual service plan (ISP);
    • date the CDS employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;
    • date the CDS employer may begin delivery of program services through the CDS employer's service providers;
    • the number of units, the approved rate, or the amount authorized in the ISP for each service to be delivered through the CDS option;
    • total funds authorized for each program service to be delivered through the CDS option; and
    • the authorized schedule of service delivery per day, week, month or other time frame specific to the service if not listed on the above forms.

    Within five business days after eligibility determination for the STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) program, new applicants who choose the CDS option are referred to the FMSA they selected to begin the initiation process.

    Within five business days of receipt of the completed Form 1584, ongoing STAR+PLUS and STAR+PLUS HCBS program members who choose the CDS option are referred to the FMSA they selected to begin the CDS initiation process.

    The MCO service coordinator provides the FMSA the following documentation:

    • Form 1584;
    • Form 1582, Consumer Directed Services Responsibilities; and
    • the ISP.

    The MCO service coordinator must provide the FMSA with the authorized schedule of service delivery per day, week, month or other time frame specific to the service if not listed on the above forms.

    Some applicants may have been anticipating the availability of the CDS option and may elect to go directly to the CDS option. The MCO service coordinator must emphasize that the applicant assumes all responsibility for arranging their self-directed services.

    MCO service coordinators must carefully coordinate transition activities when transitioning applicants or members to and from the CDS option.

     

    8241 Initiation and Orientation of the Member as Employer

    Revision 20-1; Effective March 16, 2020

     

    Upon choosing to participate in the Consumer Directed Services (CDS) option, a CDS employer and the designated representative (DR), if applicable, must:

    • complete the initial face-to-face orientation provided by the financial management services agency (FMSA) in the residence of the member or setting of the member's or legally authorized representative's (LAR's) choosing;
    • complete and maintain a copy of Form 1736, Documentation of Employer Orientation by Financial Management Services Agency, upon completion of the orientation;
    • complete Form 1735, Employer and Financial Management Services Agency Service Agreement, with the program addendums, if applicable;
    • complete Form 1726, Relationship Definitions in Consumer Directed Services;
    • as required by the member's program, complete Form 1733, Employer and Employee Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, or Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services;
    • complete Form 1728, Liability Acknowledgment;
    • submit completed original forms specified in this section to the FMSA within five business days after the date of the initial orientation; and
    • retain copies of completed documentation required by this section.

    Upon receipt of the CDS referral from the managed care organization (MCO) service coordinator, the FMSA completes the initial CDS employer orientation with the member, LAR or DR, if applicable, in the member's residence or setting of the member’s or LAR’s choosing. The FMSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the CDS employer and the FMSA.

    During the initial face-to-face orientation, the FMSA must also:

    • explain the roles, rules and responsibilities that apply to a CDS employer, provider, FMSA, MCO and state agencies, including:
      • the CDS employer budget based on the authorized service plan;
      • the hiring process, including documents and forms to be completed for new employees; and
      • managing paper and electronic timesheets, due dates, payday schedules, and disbursing employee payroll checks;
    • review and leave with the CDS employer and DR, if applicable, a printed document that clearly states the FMSA's:
      • normal hours of operation;
      • key persons to contact with issues or questions and how to contact these persons; and
      • the complaint process, including how to file a complaint with the FMSA or about the FMSA;
    • review Form 1735 and required addendums, emphasizing rule and policy requirements of the member's program, including:
      • service definitions;
      • provider qualifications;
      • required documentation to be kept in the home;
      • training requirements for service providers;
      • program staff who will be reviewing the CDS employer's records; and
      • if applicable, nursing requirements as described on Form 1747, Acknowledgement of Nursing Requirements; and
    • review and leave with the CDS employer and DR, if applicable, printed information on how to report allegations of abuse, neglect and exploitation.

    The FMSA must provide to the CDS employer or DR a printed or electronic copy of the HHSC CDS Option Employer Manual.

    Upon conclusion of the orientation, the FMSA and CDS employer must complete Form 1736, Documentation of Employer Orientation by Financial Management Services Agency.

    The FMSA must receive a completed Form 1735 with required attachments signed and dated by the CDS employer or DR before initiation of the CDS option.

    The CDS employer or DR signs and submits all required forms for participation in the CDS option and returns the forms to the FMSA within five business days after the date of initial orientation.

    The CDS employer and FMSA notify the MCO service coordinator when all initiation activities are complete. The MCO must ensure the FMSA performs all FMSA responsibilities, including providing orientation to CDS employers.

     

    8242 Employer and Employee Acknowledgment of Exemption from Nursing Licensure for Certain Services Delivered through CDS

    Revision 20-1; Effective March 16, 2020

     

    The financial management services agency (FMSA) assists the Consumer Directed Services (CDS) employer or designated representative (DR) in completing the CDS employer and employee acknowledgment of exemption from nursing licensure requirements for certain services delivered through CDS. Tasks prohibited from delegation are described in the Texas Administrative Code §225.13, Tasks Prohibited From Delegation. The employee acknowledges that, as the person who delivers the service, they have not been:

    • denied a license under Chapter 301 or 302, Occupations Code; or
    • issued a license under Chapter 301, Occupation Code, that is revoked or suspended.

    The FMSA verifies potential service providers selected by the CDS employer or DR meet provider qualifications and other requirements of STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) before the CDS employer or DR hires the service provider.

     

    8243 Authorizing CDS

    Revision 21-2; Effective August 1, 2021

     

    When the CDS employer and financial management services agency (FMSA) notify the managed care organization (MCO) service coordinator that CDS services are ready to begin, the MCO service coordinator negotiates a start date for services. The MCO service coordinator revises Form H1700-1, Individual Service Plan, and changes the applicable authorizations to the FMSA. For ongoing members, the individual service plan (ISP) year remains the same. The same procedures are followed for any other transfer of agencies.

    It is the responsibility of the CDS employer and the FMSA to ensure that the expenditures for the year remain within the authorized amount. The MCO is responsible for timely payment of FMSA claims, submitted on behalf of the CDS employer, as well as for payment of the monthly service fee, which pays the FMSA for its services.

     

    8244 Corrective Action Plans

    Revision 20-1; Effective March 16, 2020

     

    A written corrective action plan (CAP) may be required from a Consumer Directed Services (CDS) employer or designated representative (DR) if the CDS employer or DR:

    • hires an ineligible service provider;
    • submits incomplete, inaccurate, or late documentation of service delivery;
    • does not follow the budget;
    • does not comply with program requirements related to the CDS option;
    • does not meet other CDS employer responsibilities.

    The CDS employer or DR must provide a written CAP to the person requiring the plan within 10 business days after receiving a CAP request. CAPs may be requested in writing by the financial management services agency (FMSA), managed care organization (MCO), Texas Health and Human Services Commission (HHSC) staff or service planning team (SPT) member.

    The written CAP must include the:

    • reason the CAP is required;
    • action to be taken;
    • person responsible for each action; and
    • date the action must be completed.

    The CDS employer or DR may request assistance in the development or implementation of a CAP from the:

    • FMSA or others, if the plan is related to CDS employer responsibilities; and
    • MCO, if the CAP is related to the STAR+PLUS or STAR+PLUS Home and Community Based Services (HCBS) program rules or requirements.

    Form 1741, Corrective Action Plan, is used to document the CAP.

     

    8244.1 Terminating the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    A Consumer Directed Services (CDS) employer may request voluntary termination of participation in the CDS option and receive services through a program agency provider at any time. A member may also be involuntarily terminated from participation in the CDS option in accordance with the requirements of the member's program and Texas Administrative Code §41.407, Termination of Participation in the CDS Option. After terminating the CDS option, the member must wait 90 days before switching to a different service delivery option.

    A member’s managed care organization (MCO) service coordinator convenes the member's service planning team (SPT) concerning issues that may warrant immediate termination of the member's participation in the CDS option. On review of the information, the SPT may recommend immediate termination of participation in the CDS option when:

    • the member's health or safety is immediately jeopardized by the member's participation in the CDS option;
    • the designated representative (DR) has been convicted of an offense under Chapter 32 of the Penal Code or an offense barring employment as listed in the Texas Health and Safety Code, §250.006(a) and (b); or
    • HHSC or another government agency with applicable regulatory authority recommends that participation in the CDS option be immediately terminated.

    If a CDS employer or designated representative (DR) does not implement and successfully complete the following steps and interventions, a member's SPT may recommend termination of participation in the CDS option in accordance with the member's program requirements:

    • eliminate jeopardy to the member's health and safety;
    • successfully direct the delivery of program services through CDS;
    • meet CDS employer responsibilities;
    • successfully implement corrective action plans; or
    • appoint a DR or access other available supports to assist the CDS employer in meeting CDS employer responsibilities.

    Before a financial management services agency (FMSA) recommends involuntary termination of participation in the CDS option to a member's MCO service coordinator, the FMSA must:

    • provide documentation to the member's MCO service coordinator of additional and ongoing training and supports provided by the FMSA when a CDS employer or DR demonstrates noncompliance with CDS employer responsibilities;
    • provide assistance requested by the CDS employer or DR to develop and implement a corrective action plan;
    • provide documentation of any corrective action plan required of the CDS employer or DR by the FMSA in accordance with this section; and
    • notify the MCO service coordinator in writing in accordance with the requirements of the member's program when recommending termination of a member's participation in the CDS option.

    On receipt of a recommendation for involuntary termination from the FMSA or other party, the member's MCO service coordinator must:

    • provide assistance with accessing supports and developing and implementing a corrective action plan related to noncompliance with program and CDS requirements;
    • document interventions utilized by the CDS employer or DR to eliminate noncompliance with program requirements for delivery of program services through the CDS option; and
    • convene the SPT to:
      • consider recommendations related to the member's participation in the CDS option;
      • recommend additional interventions to be implemented to protect the member's health and safety for continued participation in the CDS option; and
      • make revisions to the member's service plan if needed.

    If the SPT recommends terminating participation in the CDS option, the member's MCO service coordinator must document:

    • the reasons for the recommendation;
    • the conditions and time frame established by the member's SPT that the member must meet prior to re-enrollment in the CDS option;
    • justification for any time period for a termination in excess of the minimum 90-day requirement; and
    • if applicable, the conditions and time frame specified by a hearing officer as the result of a fair hearing that upholds the termination.

    When a member's participation in the CDS option is terminated, the MCO service coordinator must take steps and interventions in accordance with the requirements of the member's program to:

    • ensure continuity of delivery of program services that were being delivered through the CDS option; and
    • document arrangements made for delivery of program services that were being delivered through the CDS option to be delivered by the member's program provider or other resources.

     

    8244.2 Re-enrollment in the CDS Option

    Revision 20-1; Effective March 16, 2020

     

    Following termination of participation in the Consumer Directed Services (CDS) option, a member or legally authorized representative (LAR) must request re-enrollment in the CDS option by notifying the member's managed care organization (MCO) service coordinator. If a member or LAR wishes to re-enroll in the CDS option, the MCO service coordinator must:

    • review the reason that the member was suspended or terminated from the CDS option;
    • verify that the member has fulfilled the minimum 90-day period and any conditions specified by the member's service planning team (SPT) or a hearing officer, if applicable;
    • verify how each issue that contributed to the suspension or termination has been resolved; and
    • refer the request for re-enrollment in the CDS option to the member's SPT and follow requirements of the member's program, including:
      • revising the member's service plan and re-enrolling the member in the CDS option upon approval; and
      • issuing a denial and providing information related to requesting a fair hearing if the request is not approved.

    If approved for re-enrollment, the FMSA must:

    • provide an initial orientation in accordance with this section, following the member's re-enrollment in the CDS option if the current CDS employer or DR has not received initial orientation; and
    • notify the CDS employer, DR, and the member's MCO service coordinator in writing within two business days after any repeat of prior noncompliance or additional noncompliance with requirements of the member's program or this section during the member's participation in the CDS option.

     

    8245 Budgets

    Revision 20-1; Effective March 16, 2020

     

    The CDS employer or designated representative (DR), with assistance obtained from the financial management services agency (FMSA) or others, must:

    • develop an initial and annual budget for each STAR+PLUS service and STAR+PLUS Home and Community Based Services (HCBS) service to be delivered through the CDS option;
    • project expenditures of funds allocated in the individual service plan (ISP) for the effective period of the ISP;
    • use a workbook approved by the managed care organization (MCO) or applicable budget workbooks available through Texas Health and Human Services Commission (HHSC) at https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/cds-forms-handbooks;
    • budget to pay employees in accordance with minimum wage laws and any other applicable base wage requirements;
    • request assistance from the FMSA as needed;
    • submit each budget to the FMSA for review of the member's budgeted payroll spending decisions and verification that the applicable budget workbooks are within the approved budget. The FMSA must work with the CDS employer or DR to resolve issues that prevent the approval of budget plans; and
    • obtain written approval for each budget from the FMSA before implementation of the budget and initiation of service delivery through the CDS option.

    An FMSA must:

    • review the CDS employer’s budgeted payroll spending decisions;
    • verify that each applicable budget workbook is within the approved budget; and
    • notify the CDS employer, in writing, of the approval or disapproval of the CDS employer’s budget and work with the CDS employer or DR to resolve issues that prevent budget approval.

    Budget Revisions and Approval

    A CDS employer or DR must make budget revisions if:

    • a change to the individual service plan (ISP) affects funding for a program service delivered through the CDS option;
    • a budget has been or will be exceeded before the end date of the ISP;
    • authorized units, unit rate or amount of funds allocated have changed;
    • an amount paid for one or more services, goods or items affects the approved budget;
    • revisions are made to a service back-up plan;
    • funds budgeted for a service back-up plan are not used or needed; or
    • the FMSA, the MCO service coordinator, the person-centered service planning team (SPT), or an HHSC representative requires a revision.

    The CDS employer or DR must submit budget revisions to the FMSA for approval. Revised budgets cannot be implemented until written approval is received from the FMSA.

    The FMSA must provide assistance to the CDS employer or DR with budget revisions as requested or needed by the member, validate the budget, and provide written approval to the CDS employer or DR.

    The MCO evaluates ISP changes requested by the CDS employer and participates in the SPT meetings to resolve issues when the CDS employer or DR does not follow the budget or comply with CDS option budget requirements.

     

    8300 Service Responsibility Option (SRO) Description

    Revision 20-1; Effective March 16, 2020

     

    The Service Responsibility Option (SRO) is a service delivery option that empowers the member or legally authorized representative (LAR) to manage most day-to-day activities. This includes supervision of the employee providing personal assistance services and respite services.

    The member or LAR decides how services are provided. SRO leaves the business details to the member's managed care organization's contracted provider. The rules for the SRO are found in Texas Administrative Code, Title 40, Chapter 43.

    See Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of all available service delivery option features.

     

    8310 SRO Roles and Responsibilities

    Revision 20-1; Effective March 16, 2020

     

    Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, specifies the roles and responsibilities assigned to the member or legally authorized representative (LAR), provider and managed care organization (MCO). The member, provider and MCO receive and sign Form 1582-SRO indicating their agreement to accept the service responsibility option (SRO) responsibilities.

     

    8311 Managed Care Organization Responsibilities

    Revision 20-1; Effective March 16, 2020

     

    The intake, referral and assessment procedures for members or legally authorized representative (LARs) requesting service delivery through the service responsibility option (SRO) are handled in the usual way. The managed care organizations (MCOs) are responsible for:

    • ensuring the member or LAR has an opportunity to make an informed choice by providing an objective and balanced review of the options; and
    • monitoring the quality of services and service delivery.

    Once the assessment is complete, the MCO is required to:

    • inform the member or LAR about all options for managing eligible services; and
    • review Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, with the member or LAR to determine if the SRO is an appropriate choice.

    In addition, the MCO's responsibilities include:

    • presenting all service delivery options;
    • documenting the member's or LAR's choice on Form 1584, Consumer Participation Choice;
    • providing a list of contracted SRO agencies;
    • explaining SRO rights, responsibilities and resources to the member or LAR;
    • presenting the MCO-contracted provider list and the support consultation provider to the member or LAR;
    • making a referral to the provider(s) selected by the member, LAR or representative;
    • processing the member's or LAR's request to change service delivery options;
    • redeveloping the individual service plan (ISP) when a member's needs change;
    • serving as a resource if the member has health or safety concerns, issues involving the attendant or other service-related concerns;
    • convening service planning team meeting in instances where the member:
      • has health and safety concerns;
      • is having difficulty selecting or keeping an attendant; or
      • has other issues relating to services that cannot otherwise be resolved; and
      • monitoring services in accordance with Section 8322, Monitoring.

     

    8312 Agency Responsibilities

    Revision 20-1; Effective March 16, 2020

     

    The agency contracted with the managed care organization (MCO) is the attendant's Consumer Directed Services (CDS) employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to policies and standards before sending the attendants to members' homes.

    The agency:

    • discusses and negotiates potential back-up plans for those times when the attendant is absent from work;
    • sends a maximum of three attendants, including any individuals recommended by the member, for the member to review;
    • explains to the selected attendants that the agency is the CDS employer of record and the member is the day-to-day manager;
    • provides agency time sheets to the member and orients the member to the time sheet submission process, including how frequently time sheets must be completed;
    • receives and processes attendant time sheets;
    • sends new attendants within the required time frame to interview at the member's or legally authorized representative's (LAR's) request; and
    • orients the member or LAR to the agency's attendant evaluation process, including forms and the schedule for evaluating attendants.

     

    8313 Member Responsibilities

    Revision 20-1; Effective March 16, 2020

     

    The member, legally authorized representative (LAR) or representative 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. To participate in the service responsibility option (SRO), the member must be capable of performing all management tasks as described below, or may identify a representative to assist or perform those management tasks on the member's behalf.

    The member is responsible for:

    • choosing the SRO;
    • choosing the SRO service and support provider(s);
    • meeting with the SRO support provider within 14 days of selecting the SRO;
    • coordinating with the agency supervisor as part of the service planning process by:
      • negotiating the type, frequency and schedule of quality assurance contacts;
      • discussing any concerns about care management;
      • requesting on-site assistance while orienting a new attendant, if desired; and
      • negotiating to develop a back-up plan for when the attendant cannot come to work;
    • selecting personal attendant(s) from candidates sent by the agency (including someone the person recommends to the agency supervisor or someone who has completed the agency pre-employment screening);
    • informing the agency supervisor within 24 hours:
      • of the personal attendant selected;
      • if the attendant gives notice of his intention to quit;
      • if the attendant quits; or
      • if the member wants to dismiss the attendant;
    • training the personal attendant on how to safely perform the approved tasks in the manner desired;
    • supervising the personal attendant;
    • ensuring the attendant only does the tasks authorized in the individual service plan (ISP) and works only the number of hours authorized in the ISP;
    • complying with agency payroll and attendance policies;
    • evaluating the attendant's job performance at the time designated by the agency;
    • reviewing, approving and signing agency employee time sheets after the attendant completes them;
    • ensuring employee time sheets are submitted to the agency within the time frames designated by the agency;
    • notifying the agency as soon as possible if the personal attendant will be absent and a substitute is needed;
    • taking responsibility for liability risk if the member or attendant is injured while doing tasks under the member's training and supervision;
    • using the following complaint procedures:
      • If the agency is not fulfilling the expected responsibilities, address those issues directly with the agency. If the agency and the member or LAR are not able to resolve the concerns/issues, the member or LAR should contact the managed care organization (MCO).
      • If concerns and issues are still not resolved, the member or LAR may select another agency. The member or LAR must contact the MCO to transfer from one agency to another. The MCO will make all necessary arrangements for the transfer.
    • notifying the MCO and/or agency supervisor of any health or safety concerns or issues with the attendant (the member or LAR may, at any time, request a service planning team (SPT) meeting); and
    • notifying the MCO and agency supervisor if a change to either the agency option or Consumer Directed Services (CDS) is desired. An SPT meeting will be held to plan for the change.

     

    8320 Managed Care Organization (MCO) Procedures

    Revision 20-1; Effective March 16, 2020

     

    The service responsibility option (SRO) is not a service; it is a service delivery option. All financial and non-financial eligibility criteria, including unmet need and "do not hire" policy, continue to apply for each program area. Unless otherwise stated in this section, MCO procedures are not impacted by the member's choice of SRO.

    Complete all forms currently required, including the assessment of functional needs on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum. Continue to identify any caregivers who are currently providing for the member's needs.

     

    8321 Initial Authorization of Services

    Revision 20-1; Effective March 16, 2020

     

    The member's or legally authorized representative’s (LAR’s) decision to receive services using the service responsibility option (SRO) does not change the manner in which initial services are authorized. See Section 3300, Administrative Procedures, for specific information.

     

    8322 Monitoring

    Revision 20-1; Effective March 16, 2020

     

    All monitoring for service responsibility option (SRO) members is done by the managed care organization (MCO) according to the mandated schedule for its specific services. When health and safety issues arise, the MCO staff:

    • discuss the issues with the agency staff;
    • talk to the member or legally authorized representative (LAR) to determine if the issues can be resolved; and
    • convene a service planning team meeting if the issue cannot be resolved.

    Because the member or LAR now shares responsibility for service delivery, the MCO, in addition to other monitoring requirements, must monitor the member's or LAR's:

    • satisfaction with the SRO; and
    • ability to comply with SRO requirements.

    If it is evident that the member or LAR is having difficulty in the management of SRO responsibilities, the MCO staff must:

    • consult the agency staff; and
    • advise the member or LAR of the option to transfer back to the agency option.

     

    8323 Presentation of the SRO

    Revision 20-1; Effective March 16, 2020

     

    Members or legally authorized representative (LARs) must be offered the service responsibility option (SRO) by the managed care organization (MCO) annually, and may request a transfer to the SRO at any time. Additionally, the SRO must be presented to ongoing members or LARs at each annual reassessment or upon request. If the member or LAR is interested in transferring to the SRO, the member or LAR must sign Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

    The MCO must ensure the member or LAR understands the responsibility they are assuming. The MCO must:

    • send Form H2067-MC, Managed Care Programs Communication, to the agency to advise the agency of the member's or LAR's selection;
    • notify the agency the member or LAR will be contacting the agency for training;
    • request the agency to advise the MCO, using Form H2067-MC, when the transition planning is complete; and
    • negotiate a start date with the member and the agency.

     

    8400 Agency Option

    Revision 20-1; Effective March 16, 2020

     

     

     

    8410 Description

    Revision 20-1; Effective March 16, 2020

     

    Under the agency option, the managed care organization (MCO) contracted provider is responsible for managing the day-to-day activities of the attendant and all business details. Most members or legally authorized representatives (LARs) select the agency option model because of the simplicity and convenience of receiving services. For example, under this option, the agency, not the member or LAR, is responsible for:

    • locating qualified attendant(s) to provide services;
    • any negligent acts or omissions by the attendant(s), and assumes liability for those acts;
    • handling all conflicts with the attendant(s);
    • any business details related to service delivery; and
    • providing basic training for the attendant(s).

    Section 9000, Utilization Review Purpose

    Section 9000, Utilization Review Purpose Anonymous (not verified) Fri, 07/22/2016 - 09:30
    Body

    Revision 19-1; Effective June 3, 2019

     

    Utilization Review (UR) is a division within the Medicaid Children's Health Insurance Program (CHIP) Services Department of the Texas Health and Human Services Commission (HHSC). UR was created by Senate Bill 348, 83rd Legislature Regular Session, 2013. This bill amended Section 533.00281 of the Texas Government Code to allow HHSC to review utilization of the STAR+PLUS Home and Community Based Services (HCBS) Program. HHSC has extended the scope of UR to include review of STAR Kids Medically Dependent Children Program (MDCP) services as well as state plan services provided in STAR Kids.

    STAR+PLUS managed care organizations (MCOs) must make information including, but not limited to, documents, assessments, notes and authorizations regarding STAR+PLUS members available upon request from UR. STAR+PLUS MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.

    Section 10000, State Plan Long Term Services and Supports

    Section 10000, State Plan Long Term Services and Supports Anonymous (not verified) Mon, 07/24/2017 - 17:01
    Body

    Revision 20-1; Effective March 16, 2020

     

     

    10100 Long Term Services and Supports

    Revision 17-5; Effective September 1, 2017

     

    Texas Medicaid offers an array of long term services and supports (LTSS) to STAR+PLUS members. Managed care organizations (MCOs) authorize LTSS in a way that reflects a member's ongoing need, based on a person-centered assessment, and a person-centered service plan. State plan LTSS are available to all STAR+PLUS members who meet functional and/or medical necessity for the services. Services include Day Activity and Health Services (DAHS), Personal Assistance Services (PAS), Community First Choice (CFC) for members who meet Level of Care eligibility, and services provided by a nursing facility.

     

    10110 Day Activity and Health Services

    Revision 17-5; Effective September 1, 2017

     

    Day Activity and Health Services (DAHS) is a Medicaid state plan service available to STAR+PLUS members who may benefit from a structured and comprehensive program that is designed to meet the needs of adults with functional impairments through an individual plan of care by providing health, social and related support services in a protective setting. Eligibility for the service is limited to members who need the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides services in a facility setting, under the supervision of a nurse. Services include nursing and nurse-delegated tasks, physical rehabilitation, nutrition, social activities and transportation to and from the facility when another means of transportation is unavailable.

     

    10111 Limitations

    Revision 17-5; Effective September 1, 2017

     

    Day Activity and Health Services (DAHS) is limited to no more than 10 hours per day and 230 hours per month, per the Medicaid State Plan, and is typically authorized for three to six hours per day. This limit may be exceeded with additional authorization from the managed care organization (MCO). Authorization for DAHS must be related to the member's chronic medical condition to be considered medically necessary and the member must have one or more functional limitations and a physician assessment indicating the potential for receiving therapeutic benefit from DAHS. Authorization relating to a primary diagnosis of mental health disorders, intellectual disabilities or related conditions is prohibited by the State Plan.

     

    10120 Day Activity and Health Services Providers

    Revision 17-5; Effective September 1, 2017

     

    Day Activity and Health Services (DAHS) is provided in a Texas Health and Human Services System licensed facility and in the community. To provide DAHS, a facility must hold a current license, be credentialed and monitored by the managed care organization (MCO), and hold an MCO contract.

    DAHS facilities are responsible for:

    • Nursing services:
      • Complete a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs and supervision of delegated tasks and personal assistance services.
      • Develop interventions to stabilize, improve or prevent complications resulting from condition consistent with physician orders and incorporated into the individual plan of care.
    • Assistance with activities of daily living occurring while the member is receiving DAHS.
    • Physical rehabilitative services, including restorative nursing, and group and individual exercises, including range of motion exercises.
    • Nutrition services:
      • One hot midday meal;
      • A midmorning and midafternoon snack;
      • Preparation of foods required for special diets; and
      • Dietary counseling and nutrition education for the member and his/her family.
    • Transportation including to and from the facility, to and from the facility on an activity outing, and to and from a facility approved to provide therapies if the member requires additional services on days of attendance at the DAHS facility. The provider must:
      • coordinate the use of other transportation resources within the community;
      • make every effort to have families transport members;
      • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by the facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety; and
      • have sufficient staff to ensure the safety of members being transported.
    • Activities and other supportive services:
      • Activities offered at the facility must be meaningful, fun, therapeutic and educational.
      • A provider must offer at least three different scheduled activities in at least one or more of the following categories:
        • Exercise;
        • Games;
        • Educational or reality orientation; and/or
        • Crafts.
      • A provider must offer at least one of the following activities monthly, at cost to the provider:
        • Trips or special events; or
        • Cultural enrichment.

     

    10130 Assessment for Day Activity and Health Services

    Revision 17-5; Effective September 1, 2017

     

    The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order. Functional need for Day Activity and Health Services (DAHS) is established by the managed care organization (MCO) service coordinator using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, or Form H6516, Community First Choice Assessment, and Form H2060-A.

    A DAHS facility nurse must complete a DAHS assessment or the MCO's equivalent process for each STAR+PLUS member at the facility. The DAHS assessment or equivalent process may be conducted by the facility nurse, based upon the member's condition at the time of initial assessment. The DAHS facility nurse completes a DAHS assessment or the MCO's equivalent process at either the facility or the member's home. DAHS assessments must be conducted, at minimum, when:

    • members need an initial assessment for prior authorization by a STAR+PLUS MCO;
    • members transfer to a new facility (conducted by the new facility);
    • at reauthorization; and
    • the DAHS nurse determines a member needs to be reassessed.

     

    10140 Reassessment for Day Activity and Health Services

    Revision 17-5; Effective September 1, 2017

     

    Reassessment for Day Activity and Health Services (DAHS) by a physician is required at least every 12 months for continued authorization. Reassessment of functional and medical necessity for DAHS is established, at least annually, by the managed care organization (MCO) service coordinator using:

    A member is reassessed at regular intervals by the facility nurse. In addition, the facility nurse assesses the member for nursing, physical rehabilitation and nutritional services when:

    • a member first enters the facility;
    • transferring from another DAHS facility; or
    • a member's condition changes resulting in the need for a new service plan due to changes in dietary restrictions, medications or other services provided by the facility. If the change in condition necessitates, the facility nurse coordinates with the member's service coordinator or physician for a physician assessment.

     

    10150 Authorization for Day Activity and Health Services

    Revision 20-1; Effective March 16, 2020

     

    To authorize Day Activity and Health Services (DAHS), the managed care organization (MCO) must obtain a physician’s assessment and complete the following forms:

    • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060; or
    • Form H6516, Community First Choice Assessment, and Form H2060-A.

    The documentation required by the MCO must be dated no more than 90 days prior to the authorization request. MCOs may issue temporary authorizations if the physician’s assessment and all forms are not submitted. Temporary authorizations are valid for at least 30 days but will expire after 60 days.  Authorizations should be updated when the member is assessed by their physician and all forms are submitted to align with the 90-day time frame between the date of assessment and authorization.

    DAHS authorizations must reflect the member's ongoing needs and should typically be valid for 12 months, unless the member experiences a significant change in condition or is admitted to a hospital or nursing facility, transfers between facilities or transfers to a new MCO. If an authorization is issued for less than 12 months, the MCO may not require a new physician’s assessment unless the member experiences a change in condition, as described in the STAR+PLUS contract(s) regarding assessment instruments, or if the change is related to changes in dietary restrictions, medications, transportation needs or other services provided by the facility.

     

    10160 Reauthorization of Day Activity and Health Services

    Revision 20-1; Effective March 16, 2020

     

    Providers of Day Activity and Health Services (DAHS) must receive reauthorization from a managed care organization (MCO) at least every 12 months in accordance with the Texas Medicaid state plan. If a member transfers to a different facility, a new authorization from the gaining facility must be obtained prior to delivery of service. Failure to obtain an authorization may result in non-payment or recoupment.

    If a member experiences a significant change in condition or is admitted to a hospital, they may need a new physician’s assessment. The DAHS facility assessment (Form 3050, DAHS Health Assessment/Individual Service Plan, or the MCO’s equivalent) and the physician’s assessment must be updated based on the member's current condition.

    If the member's physician's assessment, dietary and medication needs, and functional ability have not changed since the previous DAHS authorization, the physician may use an abbreviated form for the physician’s assessment, if permitted by the MCO. An MCO may permit the physician’s assessment to be kept on file with the provider, rather than submitted to the MCO, if the MCO conducts periodic audits of provider files.  

    MCOs may issue temporary reauthorizations if the physician’s assessment and all forms are not prepared or submitted at the same time. Temporary reauthorizations expire 60 days from receipt by the facility. Reauthorizations may be sought at any time. The reauthorization must not exceed a period of 12 months.

     

    10170 Transfer Between Facilities

    Revision 17-5; Effective September 1, 2017

     

    If a member chooses to transfer to a different Day Activity and Health Services (DAHS) facility in the same area or moves to another part of the state, the gaining facility must complete an assessment and obtain the managed care organization’s (MCO's) required documentation within 14 days for continued authorization. If the gaining facility cannot obtain required documentation within 14 days, the MCO may issue a temporary authorization to ensure continuity of care. The MCO may not require a new physician assessment if an assessment was conducted in the previous 12 months. The gaining facility should request documentation pertaining to the member, including assessments and forms from the member's former facility or the member's MCO service coordinator.

     

    10180 Transfer Between MCOs

    Revision 17-5; Effective September 1, 2017

     

     

     

    10181 New MCO Same Service Area

    Revision 17-5; Effective September 1, 2017

     

    If a member transfers managed care organizations (MCOs) in the same service area, the existing authorization for Day Activity and Health Services must be honored until the earliest of the following actions:

    • the authorization expires;
    • six months have passed; or
    • the MCO has assessed the member and issued a new authorization.

     

    10182 New MCO Different Service Area

    Revision 17-5; Effective September 1, 2017

     

    If a member moves to a different service area and a different managed care organization (MCO) and has an existing authorization for Day Activity and Health Services (DAHS), the new MCO must assist the member in locating an in-network DAHS facility and primary care provider. The new MCO must complete required forms (Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, or Form H6516, Community First Choice Assessment, and Form H2060-A). The new facility must work with the new MCO to complete the MCO's required documents and forms.

    Section 11000, Nursing Facility Services

    Section 11000, Nursing Facility Services acarreras Fri, 01/03/2020 - 18:31
    Body

    Revision 20-1; Effective March 16, 2020

     

     

    11100 CPWC Benefit for NF Residents Enrolled in STAR+PLUS or a Medicare-Medicaid Plan

    Revision 20-1; Effective March 16, 2020

     

    Custom power wheelchairs (CPWCs) are a benefit for STAR+PLUS/Medicare-Medicaid Plan (MMP) members residing in a Medicaid enrolled nursing facility (NF) when the CPWC is medically necessary and prior authorized by the Texas Health and Human Services Commission (HHSC) or its designee. CPWC is a Medicaid benefit for Medicaid-only NF residents, as well as NF residents who are dually eligible for Medicare and Medicaid.

    Eligibility Requirements

    The managed care organization (MCO) must ensure the following criteria are met to establish eligibility for the CPWC benefit for NF residents. The MCO must ensure the resident:

    • is eligible for and receiving Medicaid services, including dual-eligible NF residents, in a licensed and certified NF that has a Medicaid contract with HHSC;
    • is age 21 or older;
    • has a signed statement or written order from an attending physician certifying the CPWC is medically necessary;
    • has a signed and dated physical or occupational therapy evaluation to address functional mobility and a safety assessment that includes an evaluation of the resident’s ability to safely operate the chair; and
    • has a seating assessment completed and signed by a licensed occupational or physical therapist and a Qualified Rehabilitation Professional (QRP) documenting that the client is able to safely operate a power wheelchair and all of its medically necessary components and equipment.
      • Trials must be conducted in a power wheelchair to demonstrate the ability to independently navigate the typical obstacles found in the environment and functionally operate the powerized accessories in a safe manner.
      • The QRP must be employed by, or contracted with, the durable medical equipment (DME) provider. The QRP is not required to be contracted directly with the MCO but must be enrolled in Texas Medicaid as a performing provider under a DME provider group.
      • The QRP must be present during the seating assessment, fitting, training and delivery of the CPWC.

    The evaluation must show the resident is:

    • unable to consistently ambulate independently more than 10 feet;
    • unable to operate a manual wheelchair or independently operate other ambulation devices;
    • without cognitive impairment that would impact the ability to manipulate controls or meet other safety concerns for the resident or others;
    • unable to be positioned in a standard power wheelchair;
    • has a mobility status that would be compromised without the requested CPWC; and
    • a reasonable expectation that the resident will benefit from the use of this chair for a minimum period from six months to five years.

     

    Required Elements of a CPWC

    A CPWC is defined as a professionally manufactured wheeled mobility system that consists of a power base and customized seating system and provides motorized wheeled mobility and body support specifically for individuals with impaired mobility.

    The power mobility base may include programmable electronics and may utilize alternate input devices.

    The wheelchair must be medically necessary, adapted and fabricated to meet the individualized needs of the resident, and intended for the exclusive and ongoing use of the resident.

    For safety, all chairs must include a stop switch for use by the client sitting in the chair.

    Components of the customized seating system must be in part, or entirely usable, only by the resident for whom the power wheelchair is adapted and fabricated. This means at least one of the components of the seating system may be usable only by that resident.

    • In order to be considered customized, the seat must be specifically measured to fit the resident’s needs.
    • Customized seating may include a customized seat cushion and/or back cushion or a molded seat. The resident should have a documented condition that requires custom seating that includes, but is not limited to, one or more of the following:
      • poor trunk control;
      • contractures of elbows and/or shoulders;
      • muscle spasticity;
      • tone imbalance through shoulders and/or back;
      • kyphosis, lordosis or other skeletal deformity; or
      • lack of flexibility in pelvis or spine.
    • Molded seat-billable labor to create may not exceed 15 hours.
    • Tilt in space capabilities. The resident should have a condition that meets medical necessity for a tilt in space feature, including, but not limited to, one or more of the following:
      • documented weak upper extremity strength or a condition that leads to weakened upper extremities;
      • severe spasticity;
      • hemodynamic problems;
      • quadriplegia;
      • excess extensor tone;
      • the need to rest in a recumbent position two or more times per day when the resident cannot transfer between the bed and the wheelchair without assistance; and/or
      • be at risk for skin breakdown because of an inability to reposition in the chair to relieve pressure areas.

    For a combination power tilt and recline seating system (reclining capabilities), the resident should demonstrate the need to rest in a recumbent position two or more times per day when the resident cannot transfer between the bed and the wheelchair without assistance and/or be at risk for skin breakdown because of an inability to reposition in the chair to relieve pressure areas.

    • Power Elevating Leg Lifts. A power elevation feature involves a dedicated motor and related electronics with or without variable speed programmability, which allows the leg rest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s).
      • The resident should meet the criteria for reclining capabilities.
      • The resident should have documented limitations with upper extremity functioning that would limit their ability to use manual elevating leg rests.
      • The resident should have a condition with one of the following:
        • A musculoskeletal condition such as flexion contractures of the knees or the placement of a brace that prevents 90-degree flexion.
        • Significant edema of the lower extremities that requires leg elevation.
        • Hypotensive episodes that require frequent positioning changes.
        • Required need to maintain anatomically correct positioning and reduction of exposure to skin shear.
    • Power Seat Elevation System. A power seat elevation system is used to raise and lower the client in their seated position without changing the seat angles to provide varying amounts of added vertical access when the resident does not have the ability to stand or pivot transfer without assistance. It may address one or more of the following:
      • Facilitate independent transfers, uphill transfers and transfers across unequal seat heights to and from the wheelchair; and
      • Augment the client’s reach in cases of limited reach and range of motion in the shoulder, arm and/or hand.

    The CPWC must be:

    • designed to assist the resident to be independently mobile in their environment (this includes surfaces inside and outside the facility);
    • designed to meet the medical and physical needs of the resident and prevent or minimize any further decline;
    • for the exclusive use of the resident for whom it is authorized; and
    • the personal property of the resident for whom it is authorized.

    It becomes the personal property of the resident’s estate upon death.

     

    Prior Authorizations and Billing

    The MCO/MMP is responsible for the prior authorization and reimbursement of CPWCs.  

    When a resident changes MCO/MMP for any reason (i.e., choice, moves out of the service delivery area, etc.), and the prior authorization has already been approved but the chair has not yet been delivered to the NF resident, the MCO issuing the initial authorization is responsible for reimbursement of the CPWC. This is consistent with the Uniform Managed Care Contract, Section 5.06, Span of Coverage.

    When the MCO receives a prior authorization request from a contracted DME provider
    to construct a CPWC for an NF resident, the MCO is required to respond with a decision of approval, denial or modification within three business days of the receipt of the request.

    Medicare does not cover CPWCs for skilled nursing facility (SNF) residents. MCOs must not deny NF CPWC claims or prior authorization requests nor require a Medicare Explanation of Benefit (EOB) for dual-eligible NF residents, in compliance with Uniform Managed Care Manual (UMCM) Chapter 2.0, Claims Manual, Section VII, Claims Processing Requirements, F. STAR+PLUS and STAR Kids Services for Dual-Eligibles. STAR+PLUS MCOs and MMPs should ensure staff processing CPWC prior authorization requests and claims are informed of this benefit for dual-eligible NF residents. MCO systems must have the functionality to prevent the request of a Medicare EOB or the denial of a CPWC with a reason related to the resident having Medicare as their primary insurance.

    Denial notices should include responses that are specific and individualized, reference criteria outlined in this policy, and outline the process and timelines for filing an appeal to the decision. Refer to UMCM Chapter 3.21.

    Upon the MCO’s approval of the prior authorization request, the MCO must instruct the provider to proceed with construction of the chair and request that claims be billed directly through the MCO portal upon delivery of the chair to the NF resident. Specific billing codes should be used to identify the power base type and each accessory or component.

    To be eligible for Medicaid reimbursement, the member must be on a Medicaid NF stay at the time of assessment and upon the CPWC delivery.

    The MCO/MMP must adjudicate a clean claim within 30 days. MCOs will be required to pay providers interest at an 18 percent annual rate if a claim, or portion of a claim, remains unadjudicated beyond the 30-day claims processing deadline.

    The MCO is responsible for chair modifications and adjustments.

    The MCO/MMP is responsible for the prior authorization and reimbursement for Modifications, as described below. CPWC modifications are the replacement of components due to changes in the resident’s condition.

    • All modifications within the first six months after delivery of the chair are considered part of the purchase price.
    • Components that no longer function as they were originally designed are not considered modifications.
    • Modifications to a CPWC after the first six months following delivery must be sent for a prior authorization request due to a change in the resident’s needs, capabilities, or physical or mental status which was unknown or not anticipated. The MCO will request the following documentation to be used in the prior authorization process:
      • all changes in the resident’s mobility needs;
      • the original date of delivery;
      • the serial number of the current equipment; and
      • the cost of requested modification(s).

    The MCO/MMP is responsible for prior authorization and reimbursement for CPWC Adjustments, as described below. Adjustments require labor only and do not include the addition, modification or replacement of components or supplies needed to complete the adjustment.

    • Adjustments are allowable after the first six months following delivery of the chair. Adjustments prior to the first six months are considered part of the purchase price.
    • A maximum of one hour of labor, as needed, may be requested.
    • Adjustments do not require the purchase of supplies, as this is not defined as a repair.

    The MCO/MMP is responsible for the prior authorization and reimbursement for medically necessary CPWC replacement requests at or after five years of the original date of purchase.

    The MCO/MMP is responsible for prior authorization and reimbursement of replacement chairs prior to five years of the original date of purchase when the CPWC no longer meets the resident’s needs. Other circumstances that would warrant chair replacement prior to the passage of five years from the purchase date are indicated below:

    • Serious damage was incurred through no fault of the resident. If it is determined that the chair was damaged due to abuse by staff of the NF, the NF is responsible for replacing the chair.
    • CPWC was stolen and a police report is provided to document the theft.

    The following items are not a benefit and cannot be billed additionally:

    • Additional accessories, such as tire pumps, color upgrades, gloves, back packs, USB ports and flags. (These items are not considered medically necessary and this list is not all inclusive.)
    • Attendant control switch.
    • Elevators or platform lifts.

    In all other circumstances from those listed above, the NF is responsible for the routine maintenance and repair, including battery and battery charger replacement of the resident’s CPWC.

    Appendices

    Appendices rarefyev Tue, 09/06/2016 - 17:53

    Appendix I, Reserved for Future Use

    Appendix I, Reserved for Future Use rarefyev Wed, 09/07/2016 - 10:55

    Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet

    Appendix II, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet rarefyev Wed, 09/07/2016 - 12:57

    Appendix III, Medicaid Type Program Codes for STAR+PLUS Home and Community Based Services and Community First Choice

    Appendix III, Medicaid Type Program Codes for STAR+PLUS Home and Community Based Services and Community First Choice rarefyev Wed, 09/07/2016 - 13:03

    Appendix IV, Reserved for Future Use

    Appendix IV, Reserved for Future Use rarefyev Wed, 09/07/2016 - 13:29

    Appendix V, Reserved for Future Use

    Appendix V, Reserved for Future Use rarefyev Tue, 09/13/2016 - 16:25

    Appendix VI, STAR+PLUS Inquiry Chart

    Appendix VI, STAR+PLUS Inquiry Chart rarefyev Wed, 09/07/2016 - 13:39

    Appendix VII, Acronyms

    Appendix VII, Acronyms rarefyev Wed, 09/07/2016 - 13:40
    Body

    Revision 18-2; Effective September 3, 2018

     

    The following acronyms are used in the STAR+PLUS Program.

    Acronym Description
    AA Adaptive Aids
    ADL Activity of Daily Living
    AFC Adult Foster Care
    AL Assisted Living
    ALF Assisted Living Facility
    AO Agency Option
    APS Adult Protective Services
    CAP Corrective Action Plan
    CARE Client Assignment and Registration System
    CAS Community Attendant Services
    CBA Community Based Alternatives
    CCAD Community Care for the Aged and Disabled
    CCP Comprehensive Care Program
    CDS Consumer Directed Services
    CFC Community First Choice
    CFR Code of Federal Regulations
    CHIP Children's Health Insurance Program
    CLASS Community Living Assistance and Support Services
    CMPAS Client Managed Personal Attendant Services
    CMS Claims Management System
    CMS Centers for Medicare and Medicaid Services
    CNA Certified Nursing Assistant
    COLA Cost of Living Adjustment
    CRU Centralized Representation Unit
    CSHCN Children with Special Health Care Needs
    CSIL Community Services Interest List
    DAC Disabled Adult Child
    DAHS Day Activity and Health Services
    DBMD Deaf Blind with Multiple Disabilities
    DDS Disability Determination Services
    DDU Disability Determination Unit
    DER Data Entry Representative
    DFPS Department of Family and Protective Services
    DID Determination of Intellectual Disability
    DIU Data Integrity Unit
    DME Durable Medical Equipment
    DOB Date of Birth
    DOD Date of Death
    DR Designated Representative
    DSHS Department of State Health Services
    ERS

    ERS
    Emergency Response Service

    Enrollment Resolution Services
    FBR Federal Benefit Rate
    FC Family Care (Title XX)
    FFS Fee-for-Service
    FH Fair Hearing
    FHO Fair Hearings Officers
    FMSA Financial Management Services Agency
    GR General Revenue
    HCBS Home and Community Based Services
    HCS Home and Community-based Services
    HCSS Home and Community Support Services
    HCSSA Home and Community Support Services Agency
    HDM Home Delivered Meals
    HEART Health and Human Services Enterprise Administrative Report and Tracking System
    HHS Health and Human Services
    HHSC Texas Health and Human Services Commission
    HICAP Health Information Counseling and Advocacy Program
    HIPAA Health Insurance Portability and Accountability Act
    HIPP Health Insurance Premium Payment Program
    HMA Health Maintenance Activities
    IADL Instrumental Activity of Daily Living
    ICF-IID Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions
    IDD Intellectual or Developmental Disability
    IDT Interdisciplinary Team
    ILM Interest List Management
    IME Incurred Medical Expense
    ISP Individual Service Plan
    LAR Legally Authorized Representative
    LCSW Licensed Clinical Social Worker
    LIDDA Local Intellectual and Developmental Disability Authority
    LOC Level of Care
    LOS Level of Service
    LTC Long Term Care
    LTC-R Long-term Care Regulatory
    LTSS Long-term Services and Supports
    LVN Licensed Vocational Nurse
    MAO Medical Assistance Only
    MBI Medicaid Buy-In
    MC Managed Care
    MCO Managed Care Organization
    MCCO Managed Care Compliance & Operations
    MDCP Medically Dependent Children Program
    MDS Minimum Data Set
    Med ID Medicaid Identification Card
    MEPD Medicaid for the Elderly and People with Disabilities
    MERP Medicaid Estate Recovery Program
    MESAV Medicaid Eligibility Service Authorization Verification
    MFP Money Follows the Person
    MHM Minor Home Modifications
    MMP Medicare-Medicaid Plan
    MN Medical Necessity
    MN/LOC Medical Necessity and Level of Care
    MSHCN Members with Special Health Care Needs
    NF Nursing Facility
    OT Occupational Therapy
    PACE Program of All-inclusive Care for the Elderly
    PAS Personal Assistance Services
    PASRR Preadmission Screening and Resident Review
    PCN Patient Control Number
    PCP Primary Care Physician
    PCS Personal Care Services
    PDN Private Duty Nursing
    PES Program Enrollment Support
    PHC Primary Home Care
    PNA Personal Needs Allowance
    POC Plan of Care
    PPECC Prescribed Pediatric Extended Care Center
    PPS Premiums Payable System
    PSU Program Support Unit
    PT Physical Therapy
    QIT Qualified Income Trust
    QMB Qualified Medicare Beneficiary
    R&B Room and Board
    RN Registered Nurse
    RSDI Retirement and Survivors Disability Insurance
    RUG Resource Utilization Group
    SA Service Area
    SAS Service Authorization System
    SC Service Code
    SC Service Coordinator
    SCSA Significant Change in Status Assessment
    SDX State Data Exchange
    SG Service Group
    SLMB Specified Low-Income Medicare Beneficiaries
    SNAP Supplemental Nutrition Assistance Program
    SO State Office
    SOC Start of Care
    SOLQ State On-Line Query
    SPMI Severe and Persistent Mental Illness
    STAR+PLUS HCBS program State of Texas Access Reform PLUS Home and Community Based Services program
    SRO Service Responsibility Option
    SSA Social Security Administration
    SSI Supplemental Security Income
    SSN Social Security Number
    SSPD Special Services to Persons with Disabilities
    ST Speech Therapy
    STAR State of Texas Access Reform
    STAR+PLUS State of Texas Access Reform Plus
    STS Supplemental Transition Support
    TAC Texas Administrative Code
    TANF Temporary Assistance to Needy Families
    TAS Transition Assistance Services
    TDI Texas Department of Insurance
    THSteps-CCP Texas Health Steps – Comprehensive Care Program
    TIERS Texas Integrated Eligibility Redesign System
    TMHP Texas Medicaid & Healthcare Partnership
    TOA Type of Assistance
    TP Type Program
    TPR Third-Party Resource
    TW Texas Works
    TxHmL Texas Home Living
    UAP Unlicensed Assistive Person
    UMCC Uniform Managed Care Contract
    UMCM Uniform Managed Care Manual
    WTPY Wire Third Party Query

    Appendix VIII, Monthly Income/Resource Limits

    Appendix VIII, Monthly Income/Resource Limits rarefyev Tue, 09/13/2016 - 16:28

    Appendix IX, Time Calculation

    Appendix IX, Time Calculation rarefyev Tue, 09/13/2016 - 16:29

    Appendix X, STAR+PLUS HCBS Cost Limits

    Appendix X, STAR+PLUS HCBS Cost Limits rarefyev Wed, 09/07/2016 - 13:45

    Appendix XI, Board of Nurse Examiners Rules Pertaining to Delegation

    Appendix XI, Board of Nurse Examiners Rules Pertaining to Delegation rarefyev Wed, 09/07/2016 - 13:46
    Body

    Revision10-0; Effective September 1, 2010

     

    Refer to the Texas Administrative Code directly for the most current version of rules concerning registered nurse (RN) delegation of tasks.

     

    Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program

    Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program rarefyev Wed, 09/07/2016 - 13:52
    Body

    Revision 17-1; Effective March 1, 2017

     

    An individual entering the STAR+PLUS Home and Community Based Services (HCBS) program is designated as having high needs status if:

    • the individual is on ventilator care;
    • the individual has high-skilled nursing needs, such as tracheotomy care, wound care, suctioning or feeding tubes; and/or
    • the individual will exceed the individual service plan cost limit and has needs that will require special services or service delivery, and the community support/resources have not been identified.

    Appendix XV, Services Available from Other State Agencies

    Appendix XV, Services Available from Other State Agencies Anonymous (not verified) Mon, 03/06/2017 - 09:58

    Appendix XV-A, Department of State Health (DSHS)

    Appendix XV-A, Department of State Health (DSHS) Anonymous (not verified) Tue, 03/07/2017 - 11:15

    Appendix XV-C, Texas Veterans Commission (TVC)

    Appendix XV-C, Texas Veterans Commission (TVC) Anonymous (not verified) Tue, 03/07/2017 - 11:17

    Appendix XV-D, Texas Department of Housing and Community Affairs (TDHCA)

    Appendix XV-D, Texas Department of Housing and Community Affairs (TDHCA) Anonymous (not verified) Tue, 03/07/2017 - 11:21

    Appendix XV-E, Department of Family and Protective Services (DFPS)

    Appendix XV-E, Department of Family and Protective Services (DFPS) Anonymous (not verified) Tue, 03/07/2017 - 11:23

    Appendix XV-F, Rehabilitation Technology Resource Center

    Appendix XV-F, Rehabilitation Technology Resource Center Anonymous (not verified) Tue, 03/07/2017 - 11:24

    Appendix XVIII, Mutually Exclusive Services

    Appendix XVIII, Mutually Exclusive Services rarefyev Tue, 09/13/2016 - 16:33

    Appendix XIX, Nursing Facility Counter Logic

    Appendix XIX, Nursing Facility Counter Logic rarefyev Wed, 09/07/2016 - 16:08

    Appendix XXI, Reserved for Future Use

    Appendix XXI, Reserved for Future Use rarefyev Wed, 09/07/2016 - 16:23

    Appendix XXII, Reserved for Future Use

    Appendix XXII, Reserved for Future Use rarefyev Tue, 09/13/2016 - 16:36

    Appendix XXIII, Reserved for Future Use

    Appendix XXIII, Reserved for Future Use rarefyev Tue, 09/13/2016 - 16:37

    Appendix XXIV Minimum Standards for STAR+PLUS AFC Homes and Home Providers

    Appendix XXIV Minimum Standards for STAR+PLUS AFC Homes and Home Providers rarefyev Wed, 09/07/2016 - 16:38

    Appendix XXV, Community First Choice Support Management

    Appendix XXV, Community First Choice Support Management rarefyev Wed, 09/07/2016 - 16:43

    Appendix XXVI, Long Term Care Online Portal User Guide for Managed Care Organizations

    Appendix XXVI, Long Term Care Online Portal User Guide for Managed Care Organizations rarefyev Wed, 09/07/2016 - 16:47
    Body

    6-2016

     

    For information about document accessibility, contact accessibility@hhsc.state.tx.us

    Link to Guide

    Appendix XXVII, Reserved for Future Use

    Appendix XXVII, Reserved for Future Use rarefyev Wed, 09/07/2016 - 16:51

    Appendix XXIX, Emergency Response Service Provider Requirements and Service Initiation Requirements

    Appendix XXIX, Emergency Response Service Provider Requirements and Service Initiation Requirements Anonymous (not verified) Tue, 07/25/2017 - 10:58
    Body

    9-2017

     

    An Emergency Response Services (ERS) provider contracted with a managed care organization (MCO) must meet the following provider requirements:

    • Have emergency monitoring capability 24 hours a day, seven days a week; and
    • Be equipped to provide verifiable data using technology capable of producing a printed record of the:
      • type of alarm code (test, accidental or emergency);
      • unit subscriber number;
      • date; and
      • time of the activated alarm in seconds. 

    An ERS provider contracted with an MCO, prior to delivering the service, must meet the following service initiation requirements. Secure responders who:

    • Go to the member's home if an alarm call is made to a provider; and
    • Take appropriate action, including contacting public service personnel, based on the situation.

    Attempt to secure the names of at least two responders from a member on or before the date the provider initiates services. The exceptions are as follows:

    • If the provider is able to secure the name of only one responder from a member, the provider must:
      • designate public service personnel in place of the member's second responder; and
      • document the reason the provider could secure the name of only one responder.
    • If a provider is unable to secure the names of any responders from a member, the provider must:
      • designate public service personnel in place of the member's responders; and
      • send written notification to the service coordinator of the inability to secure the names of any responders within 14 days after initiating services.

    Administer an orientation to a responder according to the following requirements:

    • Orient a responder in person, by telephone or in writing on the responder's responsibilities on or before the date the responder is first contacted by the provider and asked to respond to an alarm call;
    • Document the following information concerning the orientation:
      • name and telephone number of the responder;
      • name of the member;
      • date the responder was secured;
      • date of orientation;
      • method of orientation; and
      • topics covered; and
    • Ensure that a responder receives written procedures on how to respond to an alarm call and document the date the procedures were provided to the responder. The provider may mail the written procedures to the responder.

    Replace a responder according to the following requirements:

    • A provider must secure a replacement responder when a member's responder is no longer able to participate.
      • If a member has two responders, a provider must secure a second responder within seven days after becoming aware that the member will no longer have two responders.
      • If a member has one responder, a provider must secure a replacement responder within four days after becoming aware that the member's sole responder is no longer able to participate.
      • If a provider is unable to secure any replacement responders, the provider must:
        • designate public service personnel in place of the replacement responders; and
        • provide the case manager with written notification within 14 days after the provider determines it cannot secure a replacement responder.
    • A provider must document the date the provider:
      • became aware that a responder was no longer able to participate; and
      • secured a replacement responder.

    Maintain a record of the names of current responders for each member.

    Retain documentation of service initiation in a member's file. 

    A responder must comply with the following service requirements. Install the equipment according to the following requirements:

    • During an initial home visit, an installer must:
      • install and make an initial test of the equipment;
      • ensure that the equipment has an alternate power source in the event of a power failure;
      • install within limits set forth in manufacturers' installation instructions; and
      • if necessary:
        • purchase a telephone extension cord;
        • connect and run a telephone extension cord not to exceed 50 feet between the wall jack and the equipment; and
        • safely tack the telephone extension cord against the wall or floorboard to prevent a hazard to a member.
    • An installer is not required to:
      • adapt the physical environment in a member's home to make it compatible with the equipment;
      • arrange or pay for relocation of the telephone; or
      • purchase or install electrical extension cords. An installer must not use an electrical extension cord when installing equipment.
    • A provider must document a failure to install the equipment, including the:
      • reason for the delay;
      • date the provider anticipates it will install the equipment or the specific reason the provider cannot anticipate a date; and
      • description of the provider's ongoing efforts to install the equipment, if applicable.

    Training a member on the use of the equipment must include:

    • Demonstrating how the equipment works;
    • Having the member activate an alarm call;
    • Explaining to the member that:
      • the member must participate in a system check each month;
      • the member must contact the provider if:
        • his telephone number or address changes; or
        • one or more of his responders change; 
      • the member must not willfully abuse or damage the equipment;
      • a responder can forcibly enter a member's home, if necessary;
      • the procedures for filing a complaint against a provider; and
    • Obtaining a signed release for forcible entry.

    Service initiation due dates are as follows:

    • The provider must initiate services within 14 days after the service effective date; and
    • If a member is not available during the time frames, the provider must initiate services within 72 hours or document reason for delay.

    An ERS provider contracted with an MCO must document any failure to initiate services by the due date. Documentation must include:

    • The reason for the delay;
    • Either the date the provider anticipates it will initiate services or specific reasons the provider cannot anticipate a service initiation date; and
    • A description of the provider's ongoing efforts to initiate services.

    A provider must maintain documentation of service initiation in a member's file.

    Appendix XXX, Relocation Function

    Appendix XXX, Relocation Function Anonymous (not verified) Tue, 07/25/2017 - 11:57

    Appendix XXXI, STAR+PLUS Members Transitioning from an NF in One Service Area to the Community in Another Service Area

    Appendix XXXI, STAR+PLUS Members Transitioning from an NF in One Service Area to the Community in Another Service Area Anonymous (not verified) Tue, 07/25/2017 - 12:23

    Forms

    Forms rarefyev Tue, 09/06/2016 - 17:50
    Body

    Health and Human Services Commission Program Support Unit staff must use all forms as published, without revision.

    Except for Forms H2060 and 4800-D, Managed Care Organization (MCO) staff may develop their own forms unless the form instructions indicate otherwise. MCO developed forms must contain, at minimum, all elements contained in the form.

    ES = Spanish version available.

    Form Title
    0003 Authorization to Furnish Information  
    1023 Request for Services Funded by General Revenue  
    1024 Individual Status Summary  
    1025 Request for Information Medicare Advantage Coordination  
    1027 Caregiver Status Questionnaire ES
    1131 Individually Identifiable Health Information Fax Transmittal  
    1578 Qualified Income Trust (QIT) Copayment Agreement ES
    1579 Referral for Relocation Services ES
    1580 Texas Money Follows the Person Demonstration Project Informed Consent for Participation ES
    1581 Consumer Directed Services Option Overview ES
    1582 Consumer Directed Services Responsibilities ES
    1582-SRO Service Responsibility Option Roles and Responsibilities ES
    1583 Employee Qualification Requirements ES
    1584 Consumer Participation Choice ES
    1585 Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES
    1586 Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
    1720 Appointment of a Designated Representative ES
    1721 Revocation of Appointment of Designated Representative ES
    1735 Employer and Financial Management Services Agency Service Agreement ES
    1740 Service Backup Plan ES
    1741 Corrective Action Plan ES
    1747 Acknowledgement of Nursing Requirements  
    1826-D Case Information Release  
    2059 Summary of Client's Need for Service  
    2110 Community Care Intake  
    2110-A Community Care Intake Nursing Facility Diversion Slot Screening  
    2115 Conflict of Interest Notification  
    2119 Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement ES
    2327 Individual/Member and Provider Agreement  
    2327-A Room and Board Amendment to the Individual and Provider Agreement  
    2330 Assessment and Service Plan Approval for Adult Foster Care  
    2442 Notification of Interest List Release Closure ES
    3050 DAHS Health Assessment/Individual Service Plan  
    3055 Physician's Orders (DAHS)  
    3632 Withdrawal Confirmation ES
    4800-D Fair Hearing Request Summary  
    4800-DA 4800-D Addendum  
    4807-D Action Taken on Hearing Decision  
    8001 Medicaid Estate Recovery Program Receipt Acknowledgement ES
    8604 Transition Assistance Services (TAS) Assessment and Authorization  
    H0025 HHSC Application for Voter Registration ES
    H1010 Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) ES
    H1027-A Medicaid Eligibility Verification  
    H1097 Affidavit for Citizenship/Identity ES
    H1200 Application for Assistance - Your Texas Benefits  
    H1200-A Medical Assistance Only (MAO) Recertification ES
    H1200-EZ Application for Assistance - Aged and Disabled (Large Print)  
    H1270 Data Integrity SAVERR Notification  
    H1350 Opportunity to Register to Vote  
    H1700-1 Individual Service Plan ES
    H1700-2 Individual Service Plan – Addendum ES
    H1700-3 Individual Service Plan – Signature Page ES
    H1700-A1 Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services ES
    H1746-A MEPD Referral Cover Sheet  
    H1746-B Batch Cover Sheet  
    H2053-B Health Plan Selection ES
    H2060 Needs Assessment Questionnaire and Task/Hour Guide ES
    H2060-A Addendum to Form H2060 ES
    H2060-B Needs Assessment Addendum ES
    H2062 STAR+PLUS Waiver Activity Record  
    H2064 Gap in Enrollment for Medicaid Managed Care Members  
    H2065-D Notification of Managed Care Program Services ES
    H2067-MC Managed Care Programs Communication  
    H2111 Interest List Notification – HCBS ES
    H2118 STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest ES
    H3034 Disability Determination Socio-Economic Report ES
    H3035 Medical Information Release/Disability Determination ES
    H3675 Application Acknowledgement ES
    H3676 Managed Care Pre-Enrollment Assessment Authorization  
    H4800 Fair Hearing Request Summary  
    H4800-A Fair Hearing Request Summary (Addendum)  
    H4803 Notice of Hearing  
    H4807 Action Taken on Hearing Decision  
    H6516 Community First Choice Assessment ES

    Upcoming Form Revisions

    Upcoming Form Revisions rarefyev Wed, 09/07/2016 - 20:54
    Body

    The forms below have recently been revised and will publish on the date listed. Do NOT use these forms until the date published.

    Publish Date Form No. and Title

    Glossary

    Glossary rarefyev Wed, 09/07/2016 - 20:56
    Body

    Revision 18-2; Effective September 3, 2018

     

    Acute care — Preventive care, primary care, and other medical care provided under the direction of a provider for a condition having a relatively short duration.

    Agency option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.

    Applicant — A person who has applied for Medicaid benefits.

    Authorized Representative  — Any person or entity acting on behalf of the individual and with the individual’s written consent.

    Centers for Medicare and Medicaid Services (CMS) — The federal agency that administers Medicare and Medicaid.

    Code of Federal Regulations (CFR) — The codified federal regulatory law that governs most federal programs, including Medicaid.

    Community First Choice (CFC) option — Personal assistance services; habilitation services focused on the acquisition, maintenance and enhancement of skills; emergency response services; and support management provided in a community setting for eligible Medicaid members in the STAR PLUS Home and Community Based Services program who have received an institutional Level of Care (LOC) determination.

    Community Living Assistance and Support Services (CLASS) — A non-capitated 1915(c) waiver which provides home and community--based services to individuals with intellectual or developmental disabilities.

    Consumer Directed Services Employer – A member or legally authorized representative (LAR), parent, or court appointed guardian who chooses to participate in the CDS option and therefore is responsible for hiring and retaining service providers to deliver program services.

    Consumer Directed Services (CDS) option — A service delivery option in which a member or LAR employs and retains service providers and directs the delivery of eligible STAR+PLUS Home and Community Based Services (HCBS) program services. A member participating in the CDS option is required to use a financial management services agency (FMSA) chosen by the member or LAR to provide financial management services.

    Days — A calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays. 

    Deaf Blind with Multiple Disabilities (DBMD) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals who are deaf and blind and have a third disability.

    Denial — Closure of an application with a finding of ineligibility.

    Designated Representative (DR) —– A willing adult appointed by the CDS employer to assist with or perform the employer's required responsibilities to the extent approved by the employer. A DR, usually a family member, is not a paid service provider and is at least age 18.

    Eligibility date — The first date all waiver eligibility criteria are met, as described in Section 3240, STAR+PLUS Home and Community Based Services Program Requirements.

    Employee (a.k.a. service provider) —– An individual who is hired, trained and managed by the employer to provide services authorized by the MCO.

    Enrollment broker — A contracted entity that assists individuals in selecting and enrolling with a managed care organization (MCO). If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP).

    Family member — A person who is related by blood, affinity or law to an individual. 

    Financial Management Services (FMS) — Assistance provided to members who manage funds associated with the services elected for self-direction. The service includes initial orientation and ongoing training related to responsibilities of being an employer and adhering to legal requirements for employers.

    Financial management services agency (FMSA) — An agency that contracts with the MCO to provide FMS to members who choose the CDS option.

    Health maintenance activity (HMA) — A task that may be exempt from delegation based on registered nurse assessment that enables the member to remain in an independent living environment, and goes beyond activities of daily living because of the higher skill level required to perform.

    Home and community-based services (HCS) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals with intellectual or developmental disabilities as cost-effective alternatives to institutional care.

    Individual service plan (ISP) — An individualized and person-centered plan in which a member enrolled in the STAR+PLUS HCBS program operated by the MCO, with assistance as needed, identifies and documents his or her preferences, strengths, and health and wellness needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The ISP is supported by the results of the member's program-specific assessment and must meet the requirements of 42 CFR §441.301.

    Individual Service Plan (ISP) Service Tracking Tool — This tool is developed at least annually by the member, the MCO and family members to document necessary MDCP services determined by the member’s team and the budget associated with delivering the services. The total cost of the member’s budget provided on this tool must be below the determined cost ceiling. This is also known as Form 2604.

    Intellectual and developmental disability (IDD) — A disability with onset during the developmental period that includes limitations in both intellectual and adaptive functioning, which covers many everyday conceptual, social, and practical skills. IDD can begin at any time, up to age 22. It usually lasts throughout a person's lifetime.

    Interdisciplinary team (IDT) — All individuals/entities involved in planning the member’s plan of care (POC). This typically includes the member, the member’s authorized representative, the service coordinator, the primary care physician, etc.

    Legally authorized representative (LAR) — A person authorized by law to act on behalf of a member, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult, as defined by state or federal law, including Texas Occupations Code §151.002(6), Texas Health and Safety Code §166.164, and Texas Estates Code Chapter 752.

    Long-term Services and Supports (LTSS) — Services, including Primary Home Care, Day Activity and Health Services, and the STAR+PLUS HCBS program, that assist members in living in the community.

    Managed Care Compliance & Operations (MCCO) — A unit within the Medicaid/Children's Health Insurance Program (CHIP) Division of HHSC that is responsible for administrative and operational aspects of administering the Medicaid managed care programs.

    Managed care organization (MCO) — An established health maintenance organization or Approved Non-Profit Health Corporation (ANHC) that arranges for the delivery of health care services. In accordance with Chapter 843 of the Texas Insurance Code, it is currently licensed as such in the state of Texas.

    Medicaid Estate Recovery Program (MERP) — A program that requires Texas Health and Human Services Commission (HHSC), as the State Medicaid agency, to recover the costs of Medicaid long-term care benefits received by certain Medicaid recipients. For further information, see the MERP website.

    Medical necessity (MN) — The medical criteria a person must meet for admission to a Texas nursing facility (NF), as defined in Texas Administrative Code, Title 40 §19.2401. 

    Member — An individual who is enrolled in and receiving services through a STAR+PLUS MCO.

    Money Follows the Person (MFP) — A process used when a member in a Medicaid-certified NF who requests to move to the community is Medicaid-eligible and approved for the STAR+PLUS HCBS program before leaving the NF.

    Mutually exclusive services — Two or more services that may not be authorized for the same individual during the same time period.

    Plan of care (POC) — A care plan the MCO develops for its members that includes acute care and LTSS. The POC is not the same as the ISP.

    Program Support Unit (PSU) — An HHSC unit with staff who support and handle certain aspects of the STAR+PLUS HCBS program, as described in Section 3300, Administrative Procedures.

    Provider — An appropriately credentialed and licensed individual, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.

    Responsible party — An individual who:

    • assists and/or represents an applicant or member in the application or eligibility redetermination process; or
    • is familiar with the applicant or member and his or her financial affairs and functional condition.

    Service coordinator — The MCO staff person with primary responsibility for providing service coordination and care management to STAR+PLUS members.

    Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal attendant services (PAS). The member decides how services are provided. It leaves the business details to a provider of the member's choosing.

    Social Security Administration (SSA) — U.S. government agency created in 1935 by President Franklin D. Roosevelt, the SSA administers the social insurance programs in the U.S. The agency covers a wide range of Social Security services, such as disability, retirement and survivors benefits.

    STAR Kids — Managed care program for recipients under the age of 21 who receive SSI, SSI-related Medicaid, and/or 1915(c) waiver services.

    STAR+PLUS Home and Community Based Services (HCBS) program — Authority granted to the state of Texas to allow delivery of community-based LTSS that assist members to live in the community in lieu of an NF.

    STAR+PLUS program — The State of Texas Access Reform Plus Medicaid managed care program in which HHSC contracts with MCOs to provide, arrange, and coordinate preventive, primary, acute and long term care covered services to adult persons with disabilities and elderly persons age 65 and over who qualify for Medicaid through the SSI program and/or the MAO program. Children under age 21, who qualify for Medicaid through the SSI program, may voluntarily participate in the STAR+PLUS program. The STAR+PLUS program is the umbrella designation that includes both the STAR+PLUS services and STAR+PLUS HCBS program.

    STAR+PLUS program specialist — The staff person responsible, along with Managed Care Compliance & Operations, for STAR+PLUS policy development.

    STAR+PLUS Services — Authority granted to the state of Texas to allow delivery of Medicaid State Plan acute care, Primary Home Care (PHC), and Day Activity and Health Services (DAHS) through a managed care delivery system statewide.

    Supplemental Security Income (SSI) — Federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind and disabled people with little or no income by providing cash to meet basic needs for food, clothing and shelter.

    Support advisor — An employee who provides support consultation to an employer, a DR, or a member receiving services through the CDS option.

    Support consultation — An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.

    Texas Administrative Code (TAC) — A compilation of all the state rules in Texas.

    Termination — Closure of an ongoing case due to a finding of ineligibility.

    Texas Health and Human Services Commission (HHSC) — Administrative agency within the executive department of the state of Texas established under Texas Government Code Chapter 531. HHSC is the single state agency charged with administration and oversight of the Texas Medicaid program, including Medicaid managed care.

    Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid provider enrollment and fee-for-service claims processing. TMHP is responsible for processing Medical Necessity and Level of Care (MN/LOC) Assessments for the waivers.

    Third-Party Resource (TPR) — Any individual, entity or program that is, or may be, liable to pay for, or provide, any medical assistance or supports to a recipient under the approved state Medicaid plan, or as part of their caregiving arrangement without pay.

    TxMedCentral — A secure Internet bulletin board the state and MCOs use to share information, as described in Section 5110, TxMedCentral Naming Convention and File Maintenance.

    Unlicensed Assistive Person (UAP) — A paraprofessional who assists individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs), and provides bedside care. A UAP may perform nursing tasks only in specific situations, as governed by the Texas Administrative Code (TAC) for the Texas Board of Nursing, Title 22, Part 11, Rules 224 and 225.

    Upgrade — An existing STAR+PLUS member who requests STAR+PLUS HCBS program services or if the MCO determines the member would benefit from the STAR+PLUS HCBS program and is granted services after meeting waiver eligibility criteria.

    Revisions

    Revisions rarefyev Tue, 09/06/2016 - 17:49

    21-2 Form Changes

    21-2 Form Changes acarreras Tue, 05/18/2021 - 15:30
    Body

    Revision Notice 21-2; Effective August 1, 2021

     

    The following change(s) were made:

    Revised Title Change
    3000 STAR+PLUS HCBS Program Eligibility and Services Changes the title of Form H1700-1 to Individual Service Plan, the title of Form H1700-2 to Individual Service Plan – Addendum, and the title of Form H1700-3 to Individual Service Plan – Signature Page. Removes the mentions of Form H1700-A, Rationale for STAR+PLUS HCBS Program Items/Services, and Form H1700-B, Non-STAR+PLUS HCBS Program Services.
    4000 Complaints, Internal MCO Appeals and State Fair Hearings Removes a reference to Form H1700-2 and changes the titles of Form H1700-1 and Form H1700-3.
    5000 Automation and Payment Issues in STAR+PLUS Changes the titles of Form H1700-1, Form H1700-2 and Form H1700-3. Removes the mentions of Form H1700-A and Form H1700-B.
    6000 Specific STAR+PLUS HCBS Program Services Changes the titles of Form H1700-1, Form H1700-2 and Form H1700-3. Removes the mentions of Form H1700-A and Form H1700-B.
    7000 STAR+PLUS HCBS Program Services Changes the titles of Form H1700-1, Form H1700-2 and Form H1700-3. Removes the mentions of Form H1700-A and Form H1700-B.
    8000 Service Delivery Options Changes the title of Form H1700-1.
    Form H1700-2, Form H1700-2S and Instructions Individual Service Plan - Addendum Changes the title and revises the English and Spanish forms and instructions.
    Form H1700-3, Form H1700-3S and Instructions Individual Service Plan – Signature Page Changes the title and revises the English and Spanish forms and instructions.
    Form H1700-A and Instructions Rationale for STAR+PLUS HCBS Program Items/Services Deletes form and instructions.
    Form H1700-B and Instructions Non-STAR+PLUS HCBS Program Services Deletes form and instructions.

    21-1 Miscellaneous Changes and New Form

    21-1 Miscellaneous Changes and New Form acarreras Mon, 01/25/2021 - 13:02
    Body

    Revision Notice 21-1; Effective May 1, 2021

     

    The following change(s) were made:

    Revised Title Change
    3125 Community Care Services Eligibility Changes the section title, consolidates CCSE policy into one section and clarifies CCSE staff roles. Removes a reference to In-Home and Family Support Program Services.
    3126 Health Insurance Premium Payment Program Moves the information previously in Section 3127.
    3421.6 Individual Service Plan Cost Exceeds 202 Percent of the Resource Utilization Group Cost Limit Clarifies language about the General Revenue funding process and adds a time frame for documentation submission.
    3630 Denial or Termination Changes the section title, clarifies denial and termination language, updates Texas Administrative Code (TAC) references and the adverse benefit notification to 10 business days and removes the Program Support Unit tables and procedures. Changes the title of Section 3631 and deletes Sections 3631.1, 3631.2, 3631.3, 3631.4 and 3631.5. Changes the title of Section 3632 and updates Sections 3632.1, 3632.2, 3632.3, 3632.4 and 3632.5. Adds Section 3632.6 and renumbers Sections 3632.7, 3632.8 and 3632.9.
    3633 Disenrollment Deletes the information previously in Sections 3633, 3633.1, 3633.2, 3633.3, 3633.4, 3633.5, 3633.6 and 3633.7. Moves the information previously in Section 3640, changes the section title, clarifies language about the disenrollment process, adds Government Code and TAC references, and adds Section 3633.1.
    6650 Time Frames for Minor Home Modifications Adds a section that outlines the time frames to complete a minor home modification.
    Form 1024 and Instructions Individual Status Summary Adds a new form and instructions to be completed and submitted when requesting General Revenue funds.

    20-2, Miscellaneous Changes

    20-2, Miscellaneous Changes acarreras Mon, 06/29/2020 - 14:14
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    2
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    Revision Notice 20-2; Effective October 1, 2020

     

    The following change(s) were made:

    Revised Title Change
    1143.1.3 STAR+PLUS Personal Assistance Services (PAS) Practitioner’s Statement of Need (PSON) Adds a section that outlines the implementation of a PSON policy.
    3621.1 Individual Service Plan Expiring Report Adds a section that outlines the time frames of reviewing and updating the ISP report.
    6420 Approval of Adaptive Aids and Medical Supplies Clarifies language regarding the type of provider that sends supporting documentation for adaptive aids and medical supplies. Clarifies language regarding MCO notices.
    6630 Minor Home Modification Service Cost Limit Adds “Minor” to the title. Adds Texas Administrative Code (TAC) and handbook references and clarifies language regarding exceeding the lifetime benefit without prior approval from HHSC.
    6710 Employment Assistance Clarifies language from the Rehabilitation Act of 1973.
    7310 Service Coordination Duties Related to Respite Care Clarifies language regarding respite authorizations.
    7500 Home-Delivered Meals Adds a TAC reference and clarifies language regarding meal delivery and requirements.
    Form 1580, Form 1580-S (Spanish) and Instructions Texas Money Follows the Person Demonstration (MFPD) Project Informed Consent for Participation Changes made in August 2020 include adding additional verification to signature; revising the complaint email box; and removing demonstration services, the Mathematica Policy Research reference and case manager and state supported living center coordinator references, and duplicate language.

     

    HHSC Deleted Policy Updates

    HHSC 16-03-002 released 3-17-16 Individual Service Plan Expiring Report Scan Call Review Process Deletes as the information is incorporated in Section 3621.1.

    20-1, Miscellaneous Changes

    20-1, Miscellaneous Changes acarreras Fri, 01/03/2020 - 11:44
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    Revision Notice 20-1; Effective March 16, 2020

     

    The following change(s) were made:

    Revised Title Change
    3413 STAR+PLUS Home and Community Based Services Program Member Transferring from One MCO to Another Within the Same Service Area Removes language containing duplicate information, adds examples and deletes incorrect time frames.
    3520 Money Follows the Person Demonstration Changes the title of Section 3521 to Money Follows the Person Demonstration Introduction and removes language indicating MFPD has ended. Adds Sections 3522, 3522.1, 3522.2, 3523, 3524 and 3525 that detail MFPD eligibility, enrollment and tracking.
    3611.1 Immediate Suspension of Services Removes “or Reduction” from the title and clarifies language.
    3631.5 Unable to Obtain Physician’s Signature Adds a new section and the procedure when unable to obtain the physician’s signature.
    5220 Money Follows the Person Demonstration Entitlement Tracking and Service Authorization System Online Data Entry Clarifies language and adds four examples.
    6230 Nursing Services in Assisted Living Facilities Corrects a reference and link to Texas Administrative Code (TAC) Title 26, §553.41.
    6530 Time Frames for Initiation of Dental Services Clarifies language.
    7110 Introduction Corrects a reference and link to TAC Title 26, Chapter 553.
    7121 AFC Homes with Four or More Residents and Members Corrects a reference and link to TAC Title 26, Chapter 553.
    8000 Service Delivery Options Renumbers sections and revises all sections to clarify language.
    10150 Authorization for Day Activity and Health Services Clarifies language.
    10160 Reauthorization of Day Activity and Health Services Changes the title and adds language.
    11000 Nursing Facility Services Adds Section 11100, CPWC Benefit for NF Residents Enrolled in STAR+PLUS or a Medicare-Medicaid Plan, regarding custom power wheelchairs.

    HHSC Policy Updates

    HHSC Policy Updates rarefyev Wed, 09/07/2016 - 20:58
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    The purpose of this section is to make the most current policy and procedures readily available via a single resource. Memoranda containing policy or procedural information will be placed on this list at the time of distribution. They will remain on the list until the information contained is completely incorporated into the handbook.

    Release Date Title
    03-17-21 HHSC 512-707-6117, Change in Eligibility Requirements for Money Follows the Person Demonstration
    06-24-16

    HHSC 16-06-003, Medicaid Type Program Identification for STAR+PLUS Home and Community Based Services and Community First Choice

    Attachment: TP Code ME Waiver and CFC

    06-20-16

    HHSC 16-06-002, Policy and Procedures for Reassessment of Community First Choice Services

    02-29-16

    HHSC 16-02-001, Community First Choice Fair Hearing Processes

    01-12-16

    HHSC 16-01-001, Form H2060, Needs Assessment Questionnaire, Completion Requirements for STAR+PLUS HCBS Members Receiving Community First Choice Services

    01-06-16

    HHSC 15-12-005, Notification of Home and Community Based Services STAR+PLUS Waiver End Date

    01-06-16

    HHSC 15-12-003, Personal Assistance Services, Emergency Response Services and Protective Supervision for HCBS STAR+PLUS Waiver Members

    12-04-15

    HHSC 15-12-002, Nurse Assessment, Training, and Supervision of Delegated Tasks for Community First Choice and Personal Care Services in Managed Care

    11-19-15

    HHSC 15-11-001, Authorizations for Community First Choice Personal Assistance Services or Habilitation

    08-26-15

    HHSC: 15-08-001, Processing Medical Necessity/Level of Care Assessments for Community First Choice (CFC) Services or Upgrading CFC Recipients to HCBS STAR+PLUS Waiver

    07-27-15

    HHSC: 15-07-004, Secure File Transfer Protocol Naming Convention for Community First Choice Assessments

    07-23-15

    HHSC: 15-07-002, Support Management in Community First Choice

    Attachment: Community First Choice Support Management Handout

    Attachment: Community First Choice Support Management Handout (Spanish)

    07-09-15

    HHSC: 15-07-001, Psychological Testing for Community First Choice Eligibility in STAR+PLUS

    05-07-15

    HHSC: 15-05-001, STAR+PLUS Policy and Procedures for Community First Choice Services

    Attachment: STAR+PLUS Community First Choice Process Flows

    Attachment: Responsible Entities in the CFC Assessment Process

    SPW Service Authorization System (SAS) Updates

    SPW Service Authorization System (SAS) Updates rarefyev Wed, 09/07/2016 - 20:59
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    The purpose of this section is to make the most current SPW SAS updates readily available via a single source. Memoranda containing SPW SAS update information will be placed on this list at the time of distribution. They will remain on the list until the information is completely incorporated into the SPW SAS Help file.

    Release Date Title

     

    Contact Us

    Contact Us rarefyev Tue, 09/06/2016 - 17:51
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    For questions about STAR+PLUS programs, please email: MCO_Handbooks@hhsc.state.tx.us

    For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us