Appendix VII, Acronyms

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

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 XI, Board of Nurse Examiners Rules Pertaining to Delegation

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

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 XXII, MCO Transition Specialist Pilot Project

Revision 22-3; Effective August 3, 2022


This information provides the details and scope of the MCO Transition Specialist Pilot (TS Pilot) Project and the requirements for MCOs involved in the two pilot service areas, Bexar and Travis. This is a federally funded Money Follows the Person Demonstration (MFPD) project with a time limited scope for calendar years 2021-2024. 

Section I. Overview 

The Centers for Medicare and Medicaid Services (CMS) approved and awarded the Texas Health and Human Services Commission (HHSC) 100% federal administrative funding within the Texas Money Follows the Person Demonstration (MFPD) to conduct the Transition Specialist Pilot project from Jan. 1, 2022 through Dec. 31, 2024. The purpose of this project is to support eligible STAR+PLUS members with serious and persistent mental illness (SPMI) who meet a nursing facility level of care (NF LOC) in transitioning to the most integrated setting of their choice. 

In the TS Pilot, participating STAR+PLUS managed care organizations (MCOs) hire a transition specialist to provide intensive psychosocial rehabilitative supports to STAR+PLUS members transitioning out of a nursing facility into the STAR+PLUS Home and Community Based Services (HCBS) program. The MCO transition specialist works within the already-existing MCO structure that supports members transitioning to community settings.

The TS Pilot will fund positions within the MCOs in two TS Pilot service areas (Travis and Bexar). 

Voluntary TS Pilot project participation is available to eligible STAR+PLUS members within the Bexar and Travis service areas. 

Section II. Legal Basis

The Money Follows the Person Demonstration (MFPD) is a component of the Texas Promoting Independence Initiative (PI) Plan. The PI Plan, most recently revised in December 2020, is required by Senate Bill 367, 77th Legislature Regular Session, 2011 and Executive Order RP-13. STAR+PLUS MCOs are required to participate in the PI initiative, pursuant to Uniform Managed Care Contract Section (“Participation in Texas Promoting Independence Initiative”).

Section III. Program Service Area: 

Travis and Bexar County service areas

Section IV. Transition Specialist Pilot Participant Requirement

Participation in the TS Pilot is voluntary. To participate, the member must meet the following requirements: 

  • be a member of an MCO participating in the TS Pilot;
  • currently live in a nursing facility;
  • intend to live within the Travis or Bexar service area; 
  • have a diagnosis of SPMI;
  • meet NF LOC criteria;
  • receive Medicaid;
  • have a desire to and be eligible to transition to the community using the STAR+PLUS HCBS program;
  • be willing to meet with the TS Pilot transition specialist throughout TS Pilot period; and
  • participate in surveys, assessments or other evaluation activities for the duration of the Pilot.

Eligible members may be identified through the Promoting Independence Initiative process outlined in the Uniform Managed Care Contract Section (“Participation in Texas Promoting Independence Initiative”). Potential participants can also be directly referred to TS Pilot via the Pre-Admission Screening and Resident Review (PASRR) process, by an MCO service coordinator, by a relocation specialist, facility staff or others. 

MCOs follow processes outlined in Section 3000 of the STAR+PLUS Handbook to assess if the member is eligible to receive STAR+PLUS HCBS services before enrolling the member in the TS Pilot. See Section 3000, STAR+PLUS HCBS Program and Eligibility Services. 

Members may voluntarily leave the TS Pilot by notifying their MCO, transition specialist, or service coordinator.

Section V. Transition Specialist Pilot Services

Members who meet TS Pilot eligibility criteria and volunteer to participate can access the supports and services provided by the MCO transition specialist, including Cognitive Adaptation Training (CAT), other therapeutic interventions, and intensive transition supports. See Section VI, Transition Specialists, for detailed list of supports and services that can be provided by the MCO transition specialist. 

The TS Pilot services do not replace existing STAR+PLUS Medicaid services and supports. For example, a TS Pilot participant would be eligible to receive needed Medicaid psychosocial rehabilitation services regardless of the services they receive from the transition specialist.   

Section VI. Transition Specialists

Transition specialists will provide the following intensive psychosocial rehabilitation and transition services to TS Pilot participants:

  1. CAT

    The transition specialist will provide CAT and related services to TS Pilot Participants and continue to provide these services upon discharge into the community for up to one year after date of discharge. CAT is a psychosocial intervention provided in the person’s home which seeks to bypass the cognitive challenges associated with mental illness to improve independent living. CAT relies on the use of environmental supports, such as signs, calendars, hygiene supplies, pill containers, and other resources to cue and sequence adaptive behavior.
  2. Intensive Transition Services

    The transition specialist will provide intensive transition services to TS Pilot participants, which include all the following:
    1. Evidenced-based skills training, including CAT. 
    2. Other therapeutic interventions, as determined to be appropriate by the MCO, fostering skills necessary to manage symptoms, obtain and maintain employment or housing, or to obtain services such as education, medical care, nutritional assistance, financial assistance, transportation, legal assistance, and resources fulfilling any basic need.
    3. Pre-Tenancy housing supports to include assisting member to access documents necessary to obtain housing, negotiating with landlords, working with the participant to locate and apply for housing and get a housing voucher if applicable.
    4. Coordination of services with MCO staff, network providers and external providers to support participants in achieving independent functioning.

      The transition specialist must collect and enter data into an HHSC-specified data system at participants’ entry into the TS Pilot, every six months while in the TS Pilot, and upon the participants’ program completion, using all the following instruments:
    5. The Questionnaire about the Process of Recovery (QPR)
    6. Personal Well-Being Index (PWB)
    7. World Health Organization Disability Assessment Scale (WHODAS 2.0)

The transition specialist must contact the member within five business days of the member expressing interest in participating in the TS Pilot to schedule an initial meeting. At this meeting, the transition specialist must obtain a signed agreement from the member to participate, collect the member’s information to determine eligibility for the TS Pilot, and schedule needed follow-up meetings.

Transition specialists must communicate at a minimum of twice a month via email or phone with the member’s service coordinator to ensure continuity of care. 

Section VII. Managed Care Organization Responsibilities

MCOs are required to perform the following activities in the manner and timeframes specified in this section. 


MCOs must hire and administratively support one full-time equivalent (FTE) transition specialist per TS Pilot service area to provide CAT and intensive transition services to TS Pilot participants. 

MCOs are required to hire transition specialists with the following qualifications:

  1. Minimum of a bachelor’s degree in health, social services or a related field and relevant experience in assisting people in transitioning from institutional settings to the community. Individuals selected for these positions must complete training specified by HHSC and demonstrate knowledge and skills in delivering the TS Pilot interventions.
  2. Preferred experience working with people with serious and persistent mental illness (SPMI), lived experience of mental illness or both.

MCOs will develop a TS Pilot program participant identification, engagement, and monitoring process which integrates the transition specialist function into the MCO’s existing infrastructure. 

MCOs are required to submit expenditures for payment as outlined in Section IX, Managed Care Organization Billing Instructions. See Section IX, Managed Care Organization Billing Instructions. 

Collaboration Requirements

  1. Collaboration with Technical Assistance Contractor

    HHSC has contracted with the University of Texas Health Science Center San Antonio (UTHSCSA) to train TS Pilot transition specialists in CAT and provide on-going technical assistance. The transition specialists are required to participate in virtual or in-person multi-day training, on-going weekly calls, and a learning community supporting the work of transitioning people out of nursing facilities into the community.

    The point of contact for UTHSCSA will be designated by UTHSCSA.
  2. Collaboration with the Third-Party Evaluator

    HHSC has contracted with the University of Texas at Austin (UT Austin) to conduct evaluation activities for the TS Pilot. MCOs are required to provide UT Austin requested data on work completed with TS Pilot Participants and help coordinate  interviews with participants and key staff in the MCOs such as the transition specialists and their supervisors. See Section VI, Transition Specialist.

    The point of contact for UT Austin will be designated by UT Austin.
  3. Collaboration with HHSC staff and contractors

    The MCO must work with staff and contractors identified by HHSC to plan and effect transitions. These may include, but are not limited to, local mental health authorities, state hospital staff and other contractors.
  4. Meetings, Conference Calls and Other Activities

    MCOs must fulfill the following requirements: 
    1. Participate in all HHSC–scheduled meetings to discuss the project. 
    2. Participate in conference or teleconference calls as requested by the HHSC project director. These may include calls with state agencies, federal funding entities and subrecipients, technical assistance entities, local stakeholders or other persons or entities related to the project. 
    3. Participate in face-to-face meetings as requested by HHSC project director. 
    4. Notify HHSC project director within one business day of receipt of a request to participate in non-routine calls and activities.

Section VIII. Managed Care Organization Performance Measures

The following requirements will be used to assess the MCOs’ effectiveness in providing the services described herein.

MCOs will submit the following reports with participant level data in a reporting format agreed upon by HHSC and MCO:

  1. Electronically submit a quarterly TS Pilot report on or before Jan. 10, April 10, July 10, and Oct.10 to HHSC. The TS Pilot runs on the calendar year from Jan. 1 through Dec. 31. The quarterly TS Pilot report will include:
    1. Name of the transition specialist, their supervisor, and any changes in these staff that might occur during the quarter.
    2. Required data and documentation described in Section VI(2), Intensive Transition Services, of this section. 
    3. Activities completed in Sections VI, Transition Specialist, of this section.
  2. All reports, documentation, and other information required of the MCO will be submitted electronically to the HHSC Innovation mailbox: If HHSC determines the MCO needs to submit deliverables by mail or fax, the MCO must send the required information to one of the following addresses:

    U.S. Postal Mail
    Texas Health and Human Services Commission
    Mental Health Contracts Management Unit (Mail Code 2058) 
    P. O. Box 149347
    Austin, TX 78714-9; 347

    Overnight Mail
    Texas Health and Human Services Commission
    Mental Health Contracts Management Unit (Mail Code 2058)
    909 West 45th Street, Bldg. 552
    Austin, TX 78751
    Fax: 512-206-5307 

Section IX.  Managed Care Organization Billing Instructions

Payments under the TS Pilot are excluded from the MCO capitation payments. The contracted MCO will submit expenditures and request payment on or before the 10th of every month following the month services were provided using the Authorization for Expenditures (Form 4116), which can be downloaded here. When required by this section, supporting documentation for reimbursement of the services and deliverables will also be submitted. At a minimum, invoices will include: 

  • name, address, and phone number of transition specialist;
  • HHSC contract or purchase order number ; 
  • itemized expenses broken down by salaries, fringe benefits, in-state travel, and supplies   
  • identification of service(s) provided; 
  • dates services were delivered; 
  • name of the person performing the activities; 
  • total hours worked for each person performing the activities; 
  • total invoice amount; 
  • a copy of the general ledger for the period which supports the budget items requesting reimbursement; and 
  • any additional supporting documentation which is required by this section or as requested by HHSC.  

Contractor will electronically submit all invoices with supporting documentation to the Claims Processing Unit with a copy to

Appendix XXIX, Emergency Response Service Provider Requirements and Service Initiation Requirements



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.