Appendix VII, Acronyms

Revision 18-2; Effective September 3, 2018

The following acronyms are used in the STAR+PLUS Program.

AAAdaptive Aids
ADLActivity of Daily Living
AFCAdult Foster Care
ALAssisted Living
ALFAssisted Living Facility
AOAgency Option
APSAdult Protective Services
CAPCorrective Action Plan
CAREClient Assignment and Registration System
CASCommunity Attendant Services
CBACommunity Based Alternatives
CCADCommunity Care for the Aged and Disabled
CCPComprehensive Care Program
CDSConsumer Directed Services
CFCCommunity First Choice
CFRCode of Federal Regulations
CHIPChildren's Health Insurance Program
CLASSCommunity Living Assistance and Support Services
CMPASClient Managed Personal Attendant Services
CMSClaims Management System
CMSCenters for Medicare and Medicaid Services
CNACertified Nursing Assistant
COLACost of Living Adjustment
CRUCentralized Representation Unit
CSHCNChildren with Special Health Care Needs
CSILCommunity Services Interest List
DACDisabled Adult Child
DAHSDay Activity and Health Services
DBMDDeaf Blind with Multiple Disabilities
DDSDisability Determination Services
DDUDisability Determination Unit
DERData Entry Representative
DFPSDepartment of Family and Protective Services
DIDDetermination of Intellectual Disability
DIUData Integrity Unit
DMEDurable Medical Equipment
DOBDate of Birth
DODDate of Death
DRDesignated Representative
DSHSDepartment of State Health Services

Emergency Response Service

Enrollment Resolution Services
FBRFederal Benefit Rate
FCFamily Care (Title XX)
FHFair Hearing
FHOFair Hearings Officers
FMSAFinancial Management Services Agency
GRGeneral Revenue
HCBSHome and Community Based Services
HCSHome and Community-based Services
HCSSHome and Community Support Services
HCSSAHome and Community Support Services Agency
HDMHome Delivered Meals
HEARTHealth and Human Services Enterprise Administrative Report and Tracking System
HHSHealth and Human Services
HHSCTexas Health and Human Services Commission
HICAPHealth Information Counseling and Advocacy Program
HIPAAHealth Insurance Portability and Accountability Act
HIPPHealth Insurance Premium Payment Program
HMAHealth Maintenance Activities
IADLInstrumental Activity of Daily Living
ICF-IIDIntermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions
IDDIntellectual or Developmental Disability
IDTInterdisciplinary Team
ILMInterest List Management
IMEIncurred Medical Expense
ISPIndividual Service Plan
LARLegally Authorized Representative
LCSWLicensed Clinical Social Worker
LIDDALocal Intellectual and Developmental Disability Authority
LOCLevel of Care
LOSLevel of Service
LTCLong Term Care
LTC-RLong-term Care Regulatory
LTSSLong-term Services and Supports
LVNLicensed Vocational Nurse
MAOMedical Assistance Only
MBIMedicaid Buy-In
MCManaged Care
MCOManaged Care Organization
MCCOManaged Care Compliance & Operations
MDCPMedically Dependent Children Program
MDSMinimum Data Set
Med IDMedicaid Identification Card
MEPDMedicaid for the Elderly and People with Disabilities
MERPMedicaid Estate Recovery Program
MESAVMedicaid Eligibility Service Authorization Verification
MFPMoney Follows the Person
MHMMinor Home Modifications
MMPMedicare-Medicaid Plan
MNMedical Necessity
MN/LOCMedical Necessity and Level of Care
MSHCNMembers with Special Health Care Needs
NFNursing Facility
OTOccupational Therapy
PACEProgram of All-inclusive Care for the Elderly
PASPersonal Assistance Services
PASRRPreadmission Screening and Resident Review
PCNPatient Control Number
PCPPrimary Care Physician
PCSPersonal Care Services
PDNPrivate Duty Nursing
PESProgram Enrollment Support
PHCPrimary Home Care
PNAPersonal Needs Allowance
POCPlan of Care
PPECCPrescribed Pediatric Extended Care Center
PPSPremiums Payable System
PSUProgram Support Unit
PTPhysical Therapy
QITQualified Income Trust
QMBQualified Medicare Beneficiary
R&BRoom and Board
RNRegistered Nurse
RSDIRetirement and Survivors Disability Insurance
RUGResource Utilization Group
SAService Area
SASService Authorization System
SCService Code
SCService Coordinator
SCSASignificant Change in Status Assessment
SDXState Data Exchange
SGService Group
SLMBSpecified Low-Income Medicare Beneficiaries
SNAPSupplemental Nutrition Assistance Program
SOState Office
SOCStart of Care
SOLQState On-Line Query
SPMISevere and Persistent Mental Illness
STAR+PLUS HCBS programState of Texas Access Reform PLUS Home and Community Based Services program
SROService Responsibility Option
SSASocial Security Administration
SSISupplemental Security Income
SSNSocial Security Number
SSPDSpecial Services to Persons with Disabilities
STSpeech Therapy
STARState of Texas Access Reform
STAR+PLUSState of Texas Access Reform Plus
STSSupplemental Transition Support
TACTexas Administrative Code
TANFTemporary Assistance to Needy Families
TASTransition Assistance Services
TDITexas Department of Insurance
THSteps-CCPTexas Health Steps – Comprehensive Care Program
TIERSTexas Integrated Eligibility Redesign System
TMHPTexas Medicaid & Healthcare Partnership
TOAType of Assistance
TPType Program
TPRThird-Party Resource
TWTexas Works
TxHmLTexas Home Living
UAPUnlicensed Assistive Person
UMCCUniform Managed Care Contract
UMCMUniform Managed Care Manual
WTPYWire Third Party Query

Appendix VIII, Monthly Income/Resource Limits

Appendix IX, Time Calculation

Appendix X, STAR+PLUS HCBS Cost Limits

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 XII, Risk Group Matrix

Revision 15-1; Effective September 1, 2015

For information about document accessibility, contact

Risk Group Matrix

Appendix XIII, Your Financial Rights in an Assisted Living Facility STAR+PLUS

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 XV, Services Available from Other State Agencies

Appendix XVI, Long Term Services and Supports Codes and Modifiers

Effective Dec. 2022

The LTSS Codes and Modifiers billing matrix is a table that provides the codes and modifiers for State Plan services utilized in STAR+PLUS as well as services specific to STAR+PLUS Home and Community Based Services (HCBS).

MCOs and providers must use the link below for services provided on or after Dec. 1, 2022.

Long Term Services and Supports Codes and Modifiers (Excel)

Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services

Revision Notice 18-1; Effective March 1, 2018

For information about document accessibility, contact

Click below to view brochure: /doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services/about-cds

Appendix XVIII, Mutually Exclusive Services

Appendix XIX, Nursing Facility Counter Logic

Appendix XX, Nursing Facility Billing Matrix

Appendix XXI, Reserved for Future Use

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 XXIII, Reserved for Future Use

Appendix XXIV Minimum Standards for STAR+PLUS AFC Homes and Home Providers

Appendix XXV, Community First Choice Support Management

Appendix XXVI, Long Term Care Online Portal User Guide for Managed Care Organizations

Revision Notice 16-2; Effective June 1, 2016

For information about document accessibility, contact

Link to Guide

Appendix XXVII, Reserved for Future Use

Appendix XXVIII, CDS Training for Service Coordinators and CDS Training Manual

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

Revision Notice 17-5; Effective September 1, 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, Reserved for Future Use

Appendix XXXI, STAR+PLUS Members Transitioning from an NF in One Service Area to the Community in Another Service Area