STAR Kids Handbook

STAR Kids Handbook rarefyev Mon, 03/20/2017 - 11:28
Body

 

Section 1000, Overview and Eligibility

Section 3000, STAR Kids Screening and Assessment and Service Planning

Section 4000, STAR Kids Community Services

Section 5000, Service Delivery Options

Section 7000, Complaint, Appeal and Fair Hearing Procedures

Section 8000, Utilization Management and Review by the State

Section 1000, Overview and Eligibility

Section 1000, Overview and Eligibility rarefyev Mon, 03/20/2017 - 14:50
Body

Revision 20-2; Effective September 1, 2020

 

Senate Bill 7 from the 83rd Legislature, Regular Session, 2013 required the Texas Health and Human Services Commission (HHSC) to create the State of Texas Access Reform (STAR) Kids program. STAR Kids is a Medicaid managed care program for children with disabilities in Texas, which integrates acute care and long term services and supports (LTSS) delivered by a managed care organization (MCO).

STAR Kids does not change or impact an individual's Medicaid eligibility, nor does STAR Kids impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, ages birth through 20, enrolled in a STAR Kids MCO are called members of the MCO. All STAR Kids members have access to service coordination, provided by an MCO employee or through a member's primary care provider, authorized by the MCO.

Service coordination is specialized care management performed by a service coordinator and includes but is not limited to:

  • identification of needs, including physical health, behavioral health services, and LTSS development of an individual service plan (ISP) to address those identified needs;
  • assistance to ensure timely and a coordinated access to an array of providers and services;
  • attention to addressing unique needs of members; and
  • coordination of Medicaid benefits with non-Medicaid services and supports, as necessary and appropriate.

All STAR Kids members receive a comprehensive assessment of their physical and functional needs by a service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI), annually. Within the time frame listed in the STAR Kids Contract, Section 8.1.39, STAR Kids Initial Screening and Assessment Process, if a member has a significant change in condition, the MCO must reassess the member and update their individual service plan (ISP), as applicable, and authorize necessary services. Upon request from the member, legally authorized representative (LAR), authorized representative (AR) or health home, the MCO must update their ISP, as applicable, and authorize necessary services.

In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering additional services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP provides respite, flexible family support services, adaptive aids, minor home modifications, employment services and transition assistance to children and young adults who meet the level of care provided in a nursing facility (NF) so they can safely live in the community. The state of Texas appropriates the program a limited number of slots, so HHSC maintains an interest list for MDCP. A child, young adult, LAR or AR may ask their MCO about how to be placed on the MDCP interest list at any time.

 

1100 Legal Basis and Values

Revision 18-1; Effective March 1, 2018

 

STAR Kids Medicaid Managed Care Program is required by Texas Government Code, §533.00253. Texas Administrative Code, Title 1, Part 15, Chapter 353, Subchapter M, Home and Community Based Services in Managed Care, and Subchapter N, STAR Kids, outline the delivery of Medically Dependent Children Program services (MDCP), as well as the STAR Kids program. Requirements pertaining to managed care organizations (MCOs) are outlined in the STAR Kids Managed Care Contract and in this handbook.

The STAR Kids Handbook includes policies and procedures to be used by all Texas Health and Human Services (HHS) agencies, and the contractors and providers in the delivery of STAR Kids Program services to eligible members.

 

1110 Mission Statement

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) mission is to provide individually appropriate Medicaid managed care services to children and young adults with disabilities to enable them to live and thrive in a setting that maximizes their health, safety and overall well-being. To achieve HHSC’s mission, the STAR Kids program is established to:

  • coordinate care across service arrays;
  • improve quality, continuity and customization of care;
  • improve access to care and provide person-centered health homes;
  • improve ease of program participation for members, managed care organizations and providers;
  • improve provider collaboration and integration of different services;
  • improve member outcomes to the greatest extent achievable;
  • prepare young adults for the transition to adulthood;
  • foster program innovation; and
  • achieve cost efficiency and cost containment.

 

1200 STAR Kids Services and Service Delivery Options

Revision 18-1; Effective March 1, 2018

 

STAR Kids members are entitled to all medically and functionally necessary services available in the same amount, duration and scope as in traditional fee-for-service Medicaid, described in the Texas Medicaid state plan and the Texas Medicaid Provider Procedure Manual (TMPPM) through the member’s selected managed care organization (MCO).

 

1210 Acute Care Services

Revision 19-1; Effective June 3, 2019

 

STAR Kids members may receive any medically necessary services through their managed care organization (MCO), and as required under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) of Individuals Under Age 21, (42 CFR Part 441). This includes, but is not limited to:

  • ambulance services;
  • audiology services, including hearing aids;
  • behavioral health services, including:
    • in-patient mental health services;
    • out-patient mental health services;
    • out-patient chemical dependency services for children;
    • detoxification services; and
    • psychiatry services;
  • birthing services provided by a certified nurse midwife in a birthing center;
  • chiropractic services;
  • dialysis;
  • durable medical equipment and supplies;
  • emergency services;
  • family planning services;
  • home health care services;
  • hospital services, inpatient;
  • hospital services, out-patient;
  • laboratory;
  • medical checkups and Comprehensive Care Program (CCP) services for children and young adults through the Texas Health Steps Program;
  • oral evaluation and fluoride varnish in conjunction with Texas Health Steps medical checkup for children six months through 35 months of age;
  • optometry, glasses and contact lenses, if medically necessary;
  • podiatry;
  • prenatal care;
  • primary care services;
  • radiology, imaging and X-rays;
  • specialty physician services;
  • therapies, including physical, occupational and speech;
  • transplantation of organs and tissues; and
  • vision services.

STAR Kids members who have other insurance, like Medicare or private insurance, will receive most of their acute care services through their primary insurance. Members receive dental care through their primary insurer, through their selected Medicaid dental maintenance organization (DMO), or through a Medicaid fee-for-service model.

 

1220 Long Term Services and Supports

Revision 19-1; Effective June 3, 2019

 

STAR Kids members who have an assessed need for long term services and supports (LTSS), identified by the STAR Kids Screening and Assessment Instrument (SK-SAI), may receive the following services through their STAR Kids managed care organization (MCO):

  • Day activity health services (DAHS) for members age 18 through 20. DAHS includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services.
  • Personal care services (PCS), 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.
  • Prescribed pediatric extended care center (PPECC), which is a facility that provides nonresidential basic services, including medical, nursing, psychosocial, therapeutic and developmental services to medically dependent or technologically dependent members under the age of 21 up to 12 hours per day.
  • Private duty nursing (PDN) is nursing services for members who meet medical necessity (MN) criteria outlined in the SK-SAI and who require individualized, continuous skilled care beyond the level of skilled nursing visits provided under Texas Medicaid home health services.

STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI and who meet an institutional level of care (LOC), may receive the following service through their STAR Kids MCO.

Community First Choice (CFC), which is available to all STAR Kids members who meet an institutional LOC for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease. Members enrolled in a §1915(c) Medicaid waiver program for individuals with an intellectual disability or related condition (ID/RC) receive CFC through their waiver provider. CFC services include:

  • Personal assistance services (PAS), also called CFC-PAS or CFC-personal care services, 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.

Note: CFC-PAS is the same service as PCS. The key difference is that CFC-PAS is part of the CFC benefit and must be reported differently. Members may choose to receive CFC-PAS only if they do not need or want CFC habilitation.

  • Habilitation, also called CFC habilitation or CFC-HAB, which provides acquisition, maintenance and enhancement of skills necessary for the member 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.
  • Support management, which is training provided to members, legally authorized representatives (LARs) or authorized representatives (ARs) on how to manage and dismiss their attendants.

STAR Kids members enrolled in the Medically Dependent Children Program (MDCP) are eligible for additional services through their MCO as a cost-effective alternative to living in an NF. Receipt of MDCP services does not impact a member's eligibility for other LTSS available in STAR Kids. Additional services available to STAR Kids members in MDCP are:

  • Adaptive aids, which are needed to treat, rehabilitate, prevent or compensate for a condition that results in a disability or a loss of function and helps a member perform the ADLs or control the environment in which they live. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources.
  • Employment assistance, which is assistance provided to a member to help the member locate paid, competitive employment in the community.
  • Financial management services (FMS) for members who choose the Consumer Directed Services (CDS) option. FMS provides assistance to members with managing 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.
  • Flexible family support services are direct care services needed because of a member's disability that help a member participate in child care, post-secondary education, employment, independent living, or support a member's move to an independent living situation.
  • Minor home modifications are physical changes to a member's residence that are needed to prevent institutionalization or to support the most integrated setting for a member to remain in the community.
  • Respite services are direct care services needed because of a member's disability that provides a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
  • Supported employment provides assistance to sustain paid, 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 members without disabilities are employed.
  • Transition assistance services are a one-time service provided to a Medicaid-eligible resident of an NF located in Texas to assist the resident in moving from the NF into the community to receive MDCP services.

 

1230 Service Delivery Options for Certain Long Term Services and Supports

Revision 18-1; Effective March 1, 2018

 

STAR Kids provides members with an array of services, as identified on the individual service plan (ISP). Services are delivered by providers contracted with managed care organizations (MCOs) to provide those services. The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services.

STAR Kids members may choose from three service delivery options for the delivery of certain long term services and supports (LTSS). The options are agency, service responsibility, and consumer directed. State plan LTSS which can be delivered through these service delivery options are:

  • Community First Choice habilitation (CFC-HAB);
  • Community First Choice personal assistance services (CFC-PAS); and
  • Personal care services (PCS).

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose from these service delivery options for the following services:

  • Employment assistance;
  • Flexible family support services;
  • Respite; and
  • Supported employment.

STAR Kids members, legally authorized representatives (LARs) or authorized representatives (ARs) may choose to participate in the agency option, consumer directed services (CDS) or service responsibility option (SRO) delivery models. Members who choose the agency model select an MCO-contracted agency to coordinate service delivery for the services on their ISP. Members who choose CDS are given the authority to self-direct certain services. If the member chooses to self-direct certain services, the MCO coordinates delivery of non-member directed services.

In the SRO model, an agency is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to agency policies and standards before sending them to the member’s home. The member, LAR or AR 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.

In the CDS model, the member, LAR or AR with assistance from a financial management service agency (FMSA), ensures all supplies necessary to provide all authorized services. These personnel may be employed directly by or through personal service agreements or subcontracts with the providers.

More information about these service delivery options is available in Section 5000, Service Delivery Options.

 

1300 Service Coordination

Revision 18-1; Effective March 1, 2018

 

All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide some service coordination functions through the member's health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members, legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing or other long-term care facility, the service coordinator must inform the member, LAR or AR about options available through home and community based services (HCBS) programs, in addition to facility-based options.

MCO service coordinators are responsible for assessing a member's needs using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP. During the annual face-to-face visit, the service coordinator must:

  • Review the member’s current short-term and long-term goals and objectives, as documented in the ISP;
  • Acknowledge and document goals and objectives the member has achieved or with which the member has made progress;
  • Acknowledge and document goals and objectives that may need to be adjusted;
  • Develop new goals and objectives with input from the member, member’s family and member’s providers;
  • Update the member’s ISP;
  • Assist with development and management of the ISP and budget for members receiving Medically Dependent Children Program (MDCP) services;
  • Inform members receiving long term services and supports (LTSS) about the consumer directed services (CDS) and service responsibility options (SROs);
  • Educate the member, LAR or AR about his or her rights regarding acts that constitute Abuse or Neglect (Child Protective Services) and Abuse, Neglect or Exploitation (Adult Protective Services); and
  • Review member rights and MCO processes for service authorization, appeals and complaints.

 

1310 Service Coordination Requirements

Revision 19-1; Effective June 3, 2019

 

Managed care organizations (MCOs) provide a different level of service coordination, depending on a member's needs. Members with more complex needs receive more service coordination than members whose needs are less complex.

Members with the highest needs are designated as Level 1 members in the STAR Kids Managed Care Contract. These members receive a minimum of four face-to-face visits from a named service coordinator annually, in addition to monthly telephone calls, unless otherwise requested by a member, legally authorized representative (LAR) or authorized representative (AR). Level 1 service coordinators must be a registered nurse (RN), nurse practitioner (NP), a physician's assistant (PA), a social worker (LMSW, LCSW, or LBSW) or licensed professional counselor (LPC) if the member's service needs are primarily behavioral. Level 1 members include those who:

  • Are enrolled in the Medically Dependent Children Program (MDCP) or Youth Empowerment Services (YES) program;
  • Have complex needs or a history of developmental or behavioral health issues (multiple outpatient visits, hospitalization or institutionalization within the past year);
  • Are diagnosed with severe emotional disturbance (SED) or serious and persistent mental illness (SPMI); or
  • Are at risk for institutionalization.

Level 2 members have specialized needs that are less complex than Level 1 members. Level 2 members receive a minimum of two face-to-face visits and six telephonic contacts annually from a named service coordinator, unless otherwise requested by the member, LAR or AR. Level 2 service coordinators must be either an RN, NP, PA, have an undergraduate or graduate degree in social work or a related field, or be a licensed vocational nurse (LVN) with previous service coordination or case management experience. Level 2 members include members who:

  • do not meet the requirements for Level 1 but receive long term services and supports (LTSS);
  • the MCO believes would benefit from a higher level of service coordination based on results from the STAR Kids Screening and Assessment Instrument (SK-SAI) and additional MCO findings;
  • have a history of substance abuse (multiple outpatient visits, hospitalization or institutionalization within the past year); or
  • are without SED or SPMI, but who have another behavioral health condition that significantly impairs function.

Level 3 members have fewer needs than Level 2 members. MCOs are required to provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make three telephonic contacts annually, at minimum. Level 3 service coordinators must have a minimum of a high school diploma or a general education diploma (GED) and direct experience working with children and young adults with similar conditions or behaviors in three of the last five years.

Members receiving Level 1 or Level 2 service coordination must have a single, named person as their assigned service coordinator. Level 3 members, LARs or ARs may request a single named service coordinator by calling the service coordination hotline on the back of their STAR Kids member ID card. In addition, the MCO must provide a named service coordinator for members who qualify for Level 3 who reside in a nursing facility or community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who are served by one of the following non-capitated 1915(c) 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). The MCO must notify members within five business days of the name and telephone number of the new service coordinator, if the service coordinator changes.

MCOs must notify all members in writing of the:

  • name of the service coordinator;
  • telephone number of the service coordinator;
  • minimum number of contacts they will receive every year; and
  • types of contacts they will receive.

 

1320 Service Coordination and Programs Serving Members with Intellectual or Developmental Disabilities

Revision 18-1; Effective March 1, 2018

 

Members who have intellectual and developmental disabilities (IDD) living 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 and some long term services supports (LTSS) (e.g., private duty nursing (PDN)) through STAR Kids and continue to receive most of their LTSS through the following programs:

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

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, legally authorized representative’s (LAR’s) or authorized representative’s (AR’s) personal preference.

These members also have a person(s) outside of the MCO who develops and implements a service plan 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 their 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 these members’ acute care services and capitated LTSS.

 

1330 Service Coordination and the Youth Empowerment Services Program

Revision 18-1; Effective March 1, 2018

 

Members who receive services through the Youth Empowerment Services (YES) program receive their acute care services and some long term services and supports (LTSS) (e.g., day activity and health services (DAHS), private duty nursing (PDN), and Community First Choice (CFC)) only through STAR Kids and continue to receive their waiver services through the YES program. Members served by the YES program will have a named managed care organization (MCO) service coordinator and will be considered Level 1 members.

These members also have a case manager outside of the MCO who develops and implements a YES service plan and monitors waiver service delivery. This case management is provided through the capitated Mental Health Targeted Case Management (MH TCM) benefit, which the MCO must authorize for any member receiving YES. The MCO service coordinator must respond to requests from the member's waiver case manager. The member’s waiver case manager 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 either in person or telephonically. The MCO service coordinator is responsible for the coordination of these member's acute care services and capitated long term services and supports.

 

1340 Service Coordinators and Home and Community Based Services - Adult Mental Health

Revision 18-1; Effective March 1, 2017

 

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

  • a history of extended (three cumulative or consecutive years of the past five) institutional stays in psychiatric facilities;
  • severe mental illness (SMI) and frequent visits to the emergency department; and
  • SMI 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 basis for members age 18 and up. Each participant 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 the Texas Department of State Health Services (DSHS). Additional information about HCBS-AMH can be found at https://www.dshs.state.tx.us/mhsa/hcbs-amh/.

Program Point of Contact

Each managed care organization (MCO) must have a designated program point of contact (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 the Texas Health and Human Services Commission (HHSC) or recovery managers (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 coordinators must participate in telephonic recovery plan meetings, as scheduled by HHSC or RMs, and provide any requested member-specific information prior to the meeting. Service coordinators must:

  • Send requested information to the RM or HHSC three business days prior to the scheduled recovery plan meeting. This information includes, but is not limited to the following:
    • Updating the member’s 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 HHSC and the RM when a member transitions into or out of HCBS-AMH.

HCBS-AMH may provide transitional planning for members who reside in an institution and also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the 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 Kids MCOs must follow all discharge planning requirements, as outlined in the STAR Kids Managed Care Contract, Section 8.1.38.10.

 

1350 Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 18-1; Effective March 1, 2018

 

This section is reserved for future use.

 

1400 Medically Dependent Children Program

 

Revision 18-1; Effective March 1, 2018

 

The Medically Dependent Children Program (MDCP) is a home and community based services (HCBS) program authorized under §1915(c) of the Social Security Act. MDCP provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, employment assistance, supported employment and financial management services through a STAR Kids managed care organization (MCO). This section provides an overview of MDCP, including its eligibility requirements.

 

1410 MDCP Program Goal

Revision 18-1; Effective March 1, 2018

 

The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults age 20 and younger who are medically dependent, and to encourage de-institutionalization of children and young adults who reside in nursing facilities (NFs).

MDCP accomplishes this goal by:

  • enabling children and young adults who are medically dependent to remain safely in their homes;
  • offering cost-effective alternatives to placement in NFs and hospitals; and
  • supporting families in the role as the primary caregiver for their children and young adults who are medically dependent.

 

1500 Medically Dependent Children Program Eligibility

Revision 19-1; Effective June 3, 2019

 

Individuals become eligible to be assessed for Medically Dependent Children Program (MDCP) services when their names come to the top of the MDCP interest list. Individuals may be placed on the interest list on a first come, first served basis by contacting the Texas Health and Human Services Commission (HHSC) or their managed care organization (MCO) if they are already enrolled in STAR Kids. Once an individual's name comes to the top of the list, determination of eligibility begins as the individual applies for services. Individuals not already enrolled in STAR Kids are referred to as applicants. Individuals enrolled in STAR Kids who are assessed for MDCP are referred to as members.

MDCP 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 the MDCP waiver, the applicant or member must meet the following criteria:

  • medical necessity (MN) for an NF level of care (LOC);
  • have an individual service plan (ISP) with services under the established cost limit;
  • have an unmet need for at least one waiver service;
  • be birth through age 20;
  • be a United States citizen and Texas resident;
  • be in an appropriate living situation; and
  • have full Medicaid eligibility.

 

1510 Medical Necessity Determination

Revision 18-2; Effective September 3, 2018

 

A Medically Dependent Children Program (MDCP) waiver applicant or member must have a valid medical necessity (MN) determination before admission into the MDCP waiver. The determination of MN is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The applicant's or member's individual service plan (ISP) cost limit is calculated based on information gathered through the SK-SAI MDCP module.

The managed care organization (MCO) completes and submits the SK-SAI to Texas Medicaid & Healthcare Partnership (TMHP) for MDCP applicants/members. TMHP processes the SK-SAI 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 waiver programs to categorize needs for applicants or members and establish the service plan cost limit.

When TMHP processes an SK-SAI, a three-alphanumeric digit RUG is generated and appears in the TMHP Long Term Care (LTC) Online Portal as well as the MCO's response file. An SK-SAI with incomplete RUG information results in a "BC1" code instead of a RUG value. An SK-SAI resulting in 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 MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 days of submitting the assessment that resulted in a BC1 code. The MCO nurse must also submit any corrections to SK-SAI items used to determine MN within 14 days. After 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to TMHP. See Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for detailed instructions pertaining to communicating corrections and inactivations to the SK-SAI to TMHP.

 

1511 Medical Necessity Determination for Applicants/Members Residing in Nursing Facilities

Revision 18-1; Effective March 1, 2018

 

During initial contact with the applicant or member, the service coordinator must explore the applicant’s or member's status in the nursing facility (NF) and desire to transition to the community. The service coordinator completes the STAR Kids Screening and Assessment Instrument (SK-SAI) and submits the assessment to Texas Medicaid & Healthcare Partnership (TMHP) indicating a request for a determination of medical necessity. This process is described in more detail in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

 

1512 Medical Necessity Determination for Applicants/Members Not Residing in Nursing Facilities

Revision 18-1; Effective March 1, 2018

 

For applicants or members not living in nursing facilities (NFs), the medical necessity (MN) determination is made by Texas Medicaid & Healthcare Partnership (TMHP) based on the STAR Kids Screening and Assessment Instrument (SK-SAI) completed by the managed care organization (MCO) selected by the applicant or member.

The MCO must electronically submit the SK-SAI to TMHP indicating a request for MN determination after obtaining a physician signature using Form 2601, Physician Certification. The SK-SAI and Form 2601 must be retained in the MCO’s records.

 

1520 Individual Cost Limit

Revision 18-1; Effective March 1, 2018

 

The cost of Medically Dependent Children Program (MDCP) services cannot exceed 50 percent of the cost of care the state would pay if the member was served in a nursing facility (NF). For initial eligibility, the MDCP applicant must have an individual service plan (ISP) of MDCP services developed that is at or below 50 percent of the cost to provide services to that applicant, based on the Resource Utilization Group (RUG) in a nursing facility.

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

 

1530 Unmet Need for at Least One Waiver Service

Revision 18-2; Effective September 3, 2018

 

The 1915(c) Medically Dependent Children Program (MDCP) waiver specifies that individuals must have a need for at least one MDCP service to receive MDCP waiver services. For initial and continued eligibility for the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. Therefore, an MDCP ISP which has $0.00 as the “Total Est. Waiver Cost” at the bottom of Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, will be rejected. Members who do not use at least one MDCP service per ISP year are subject to disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for medical assistance only (MAO) Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a 1915(c) waiver program must meet eligibility requirements stated in 42 Code of Federal Regulations (CFR) §441.510(d). This CFR rule mandates that individuals who qualify for MAO Medicaid must meet all MDCP waiver requirements and also must receive one MDCP waiver service per month.

 

1540 Age

Revision 18-1; Effective March 1, 2018

 

To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

 

1550 Citizenship

Revision 19-1; Effective June 3, 2019

 

As part of Public Law 109-171, Deficit Reduction Act of 2005, each U.S. citizen eligible for Medicaid is required to provide proof of U.S. citizenship and identity. This requirement affects all long term services and supports (LTSS) members whose financial eligibility is based on a determination from Medicaid for the Elderly and People with Disabilities (MEPD) specialists. MEPD specialists also verify an applicant is a Texas resident. HHSC will have the responsibility of verifying citizenship.

 

1560 Living Arrangement

Revision 18-1; Effective March 1, 2018

 

Managed care organization (MCO) service coordinators must confirm that the applicant or member, if under age 18, lives with a family member such as a parent, guardian, grandparent or sibling, as defined in the Glossary. The MCO service coordinator must review guardianship documentation or obtain a statement from the applicant, member, legally authorized representative (LAR), authorized representative (AR) or family member regarding relation. The service coordinator must maintain this documentation in the member's case file.

 

1570 Financial Eligibility

Revision 18-2; Effective September 3, 2018

 

Applicants or members who receive Supplemental Security Income (SSI) are already eligible for Medicaid and will not require a financial or Medicaid eligibility decision. The Social Security Administration (SSA) has already made this determination. Program Support Unit (PSU) staff must determine if an applicant or member is currently on Medicaid.

 

1600 Disclosure of Information

Revision 18-2; Effective September 3, 2018

 

 

 

1610 Confidential Nature of a Case Record

Revision 18-1; Effective March 1, 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, legally authorized representative (LAR) 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.

 

1611 Establishing Identity for Contact Outside the Interview Process

Revision 18-2; Effective September 3, 2018

 

All information that the Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) have about a member or any individual on the member's case must be kept confidential. Confidential information includes, but is not limited to, a member's name, date of birth (DOB), address, Social Security number (SSN), Medicaid ID number or any other personally identifiable health information.

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

 

1611.1 Telephone Contact

Revision 18-1; Effective March 1, 2018

 

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

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

Establish the identity of a legally authorized representation (LAR) or authorized representative (AR) by using the individual's knowledge of any of the above or the any of the following:

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

Establish the identity of an attorney, LAR or AR by asking for the individual to provide Form 1826-D, Case Information Release, completed and signed by the member. The managed care organization (MCO) must maintain this documentation in the member's case file.

Texas Health and Human Services Commission (HHSC) staff must use established regional procedures to confirm the identity of legislators or their staff. The MCO must use established HHSC procedures to confirm the identity of legislators or its staff.

 

1611.2 In-Person Contact

Revision 18-1; Effective March 1, 2018

 

Establish the identity of the individual who presents himself or herself as a member, legally authorized representative (LAR) or 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:
    • Valid U.S. passport;
    • driver license or Department of Public Safety Identification card; or
    •  state agency employee badge; and
  • at least two forms of other identification:
    • Social Security number (SSN) card;
    • hospital record;
    • work or school identification card;
    • voter registration card; or
    • wage stub.

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 confidential information through one of the following:

  • official correspondence or a telephone call from a state or regional office; or
  • contact with an HHSC attorney.

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 1611.3, Verification and Documentation, if the individual is requesting personally identifiable information (PII) or protected health information (PHI).

 

1611.3 Verification and Documentation

Revision 18-1; Effective March 1, 2018

 

It is only acceptable to disclose personally identifiable information (PII) or protected health information (PHI) to the applicant, member, legally authorized representative (LAR), authorized representative (AR) or a third-party to whom the applicant, member, LAR 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:
    • Valid U.S. passport;
    • driver license or Department of Public Safety Identification card; or
    •  state agency employee badge; and
  • at least two forms of other identification:
    • Social Security number (SSN) card;
    • hospital record;
    • work or school identification card;
    • voter registration card; or
    • wage stub.

 

1612 Custody of Records

Revision 17-1; Effective June 1, 2017

 

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information they contain, except as provided by the Texas Health and Human Services Commission (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.

 

1613 Disposal of Records

Revision 17-1; Effective June 1, 2017

 

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 Section 7.06 of the STAR Kids Managed Care Contract.

 

1614 When and What Information May Be Disclosed

Revision 20-2; Effective September 1, 2020

 

Reasonable effort must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information from the 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 a member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the member.

Give member addresses or other case information only to a person who has written permission from the applicant, member, legally authorized representative (LAR) or authorized representative (AR) to obtain the information. The applicant, member, LAR 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 (DOB) 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 member, LAR or AR. Withhold confidential information 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, LAR or AR.

Note: If the case information to be released includes individually identifiable health information, the document must also tell the applicant, member, LAR 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 their survivors.

The Office of the Chief Counsel at HHSC handles questions about the release of information. All questions and problems encountered by individuals concerning release of information should be referred to this office. MCO staff should email HPM_Complaints@hhsc.state.tx.us or use the online question and complaint form.

 

1615 Confidential Nature of Medical Information ─ Health Insurance Portability and Accountability Act

Revision 18-1; Effective March 1, 2018

 

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an applicant or member and that relates to the:

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

Protected health information (PHI) includes, but is not limited to, an individual's name, date of birth (DOB), address, Social Security number (SSN), Medicaid ID number or any other personally identifiable information (PII).

 

1616 Privacy Notice

Revision 18-2; Effective September 3, 2018

 

Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) staff must send each member the Texas 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, legally authorized representative (LAR) or authorized representative (AR) about:

  • member privacy rights;
  • the duties of HHSC and the MCO to protect health information (PHI); and
  • how HHSC and the MCO may use or disclose health information without member 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.

 

1617 Member Authorization

Revision 18-1; Effective March 1, 2018

 

The member, legally authorized representative (LAR) or authorized representative (AR) may authorize the release of health information from Texas Health and Human Services Commission (HHSC) and managed care organization (MCO) records by using a valid authorization form. Form 1826-D, Case Information Release, includes all the authorization elements required by Health Insurance Portability and Accountability Act (HIPPA) privacy regulations.

 

1618 Minimum Necessary Information Release

Revision 17-1; Effective June 1, 2017

 

Reasonable efforts must be made to limit the use, request or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of individual medical information 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 a member authorizes release of income verification, including disability income, do not release related case medical information unless specifically authorized by the member.

 

1619 Legally Authorized Representatives and Authorized Representatives

Revision 18-1; Effective March 1, 2018

 

Only the member's legally authorized representative (LAR) or authorized representative (AR) can exercise the member's rights with respect to individually identifiable health information. Therefore, only a member's personal representative may authorize the use or disclosure of individually identifiable health information or obtain individually identifiable health information on behalf of a member. Exception: Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) are not required to disclose the information to the personal representative if the member is subjected to domestic violence, abuse or neglect by the personal representative. Consult appropriate legal counsel, as described in Section 1614, When and What Information May Be Disclosed, if it is believed that health information should not be released to the LAR or AR.

Note: A responsible party is not automatically an LAR or AR.

 

1619.1 Adults and Emancipated Minors

Revision 18-1; Effective March 1, 2018

 

If the member is an adult or emancipated minor, including married minors, the member's LAR or 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 appropriate legal counsel, as described in Section 1614, When and What Information May Be Disclosed, for approval.

 

1619.2 Unemancipated Minors

Revision 18-1; Effective March 1, 2018

 

A parent is the LAR or AR for a minor child except when:

  • the minor child can consent to medical treatment by himself or herself. 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 by himself or herself when the:
    • minor is on active duty with the U.S. military;
    • minor is age 16 years or older, lives separately from the parents and manages 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 of Texas;
    • 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.

 

1619.3 Deceased Members

Revision 18-1; Effective March 1, 2018

 

The LAR or AR for a deceased member is an executor, administrator or other person with authority to act on behalf of the 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 appropriate legal counsel, as described in Section 1614, When and What Information May Be Disclosed, about whether a particular person is the personal representative of an applicant or member.

 

1620 Correcting Information

Revision 19-1; Effective June 3, 2019

 

A member, legally authorized representative (LAR) 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 member and any other individual on the member's case.

A request for correction must be in writing and:

  • identify the individual asking for the correction;
  • identify the disputed information about the individual;
  • 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 member.

If HHSC or the MCO agrees to change individually identifiable health information, 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 member, LAR or AR in writing within 60 days (using current agency letterhead) that the information is corrected, or will not be corrected, and the reason. Inform the member if HHSC or the 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 individually identifiable health information, 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 it to the disadvantage of the member. HHSC staff must contact the HHSC privacy officer for a record of disclosures. MCOs must follow HHSC procedures as stated in the STAR Kids Managed Care Contract.

Note: Do not follow above procedures when the accuracy of information provided by a member, LAR or AR is determined by another review process, such as a:

  • fair hearing;
  • civil rights hearing; or
  • other appeal process.

The decision in that review process is the decision on the request to correct information.

 

1630 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 individually identifiable health information to be shared only with his or her 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 Program Support Unit (PSU) Operations staff. 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: Uploaded XX_2067_123456789_ABCD_IM_MFP.doc in SUPSKW at 8:54 a.m. on December 20. Should have been uploaded to MOLSKW. Corrected at 9:22 a.m. December 20.

All emails containing member information must be sent using encryption software. No personally identifiable information (PII) may appear in the subject line. See also Section 1615, Confidential Nature of Medical Information, and Section 5100, Agency Option (AO).

 

1640 Alternate Means of Communication

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, legally authorized representative’s (LAR’s) or authorized representative’s (AR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member, LAR 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 member.

 

1700 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 can be found in Chapter 3.4 Medicaid Managed Care Member Handbook of the Uniform Managed Care Manual at: https://hhs.texas.gov/services/health/medicaid-chip/provider-information/contracts-manuals/texas-medicaid-chip-uniform-managed-care-manual.

The Member Handbook must be provided to the member, legally authorized representative (LAR) or authorized representative (AR) at application. This document is shared in the language preference expressed by the applicant or member.

In addition, a member or LAR may refer to the Texas Administrative Code, Title 1 Administration, Part 15 Texas Health and Human Services Commission, Chapter 353, Medicaid Managed Care, Subchapter C, Member Bill of Rights and Responsibilities to view the full list of member rights and responsibilities. The Texas Administrative Code is available at: http://texreg.sos.state.tx.us/public/readtac$ext.viewtac.

 

1800 Notifications

Revision 19-1; Effective June 3, 2019

 

 

1810 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, legally authorized representative (LAR) 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, LAR or AR of the actions taken regarding the Medically Dependent Children Program (MDCP). The form must be completed in plain language that can be understood by the applicant, member, LAR or AR. The language preference of the member must be considered.

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

Form H2065-D is also used to notify an applicant, LAR or AR who is denied or a member, LAR or AR whose program eligibility is terminated. PSU staff must notify the applicant, LAR or AR on Form H2065-D of the denial of application within two business days of the decision. See also Section 6000, Denials and Terminations.

Once it is determined that a case action must be taken, Form H2065-D must be prepared and mailed to the member, LAR or AR the same date the form is signed. Notification forms must be uploaded to the managed care organization's (MCO’s) XXXSKW folder using the correct naming convention in TxMedCentral on the case action date. PSU staff's signature date on Form H2065-D is the case action date.

Depending on when the notification is generated, it will either be uploaded to the MCO's STAR Kids folder in TxMedCentral or generated in the Long-Term Care (LTC) Online Portal on the case action date.

 

1820 MCO Notification Requirements

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) is responsible for notifying the member, legally authorized representative (LAR) or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member, LAR or AR has a right to appeal. Appeal rights of STAR Kids members are in the STAR Kids Managed Care Contract.

Section 2000, Medically Dependent Children Program Intake and Initial Application

Section 2000, Medically Dependent Children Program Intake and Initial Application rarefyev Mon, 03/20/2017 - 16:31
Body

Revision 20-3; Effective December 1, 2020

 

2010 Initial Requests for Medically Dependent Children Program

Revision 18-2; Effective September 3, 2018

 

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list according to the date and time of the request, regardless of the program's enrollment status. Each individual is released from the interest list in the order of the request date. An individual is placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual's name may only be added to the MDCP interest list if the individual is less than age 21 and resides in Texas.

 

2020 Individual Who Receives STAR Health

Revision 19-1; Effective June 3, 2019

 

See the Uniform Managed Care Manual (UMCM) for STAR Health members. The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.

An individual enrolled with a STAR Health managed care organization (MCO) must remain enrolled with the STAR Health MCO.

Additional information on MDCP STAR Health members is located in the STAR Health MDCP Policy §16.2 of the UMCM.

 

2021 Individual Who Receives Other Types of Medicaid

Revision 18-2; Effective September 3, 2018

 

An individual who receives other types of Medicaid (i.e., non-Supplemental Security Income (SSI) and is either served in fee-for-service or enrolled with a STAR managed care organization (MCO) must select a STAR Kids MCO.

 

2030 Managed Care Organization Coordination

Revision 20-3; Effective December 1, 2020

 

The STAR Kids managed care organization (MCO) has 30 days from receiving the initial authorization to begin the assessment process in Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, from Program Support Unit (PSU) staff to complete all assessments for an individual applying for the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation, for a total of 60 days following the initial notice from PSU staff. Within 60 days of the MCO receiving Form H3676, the MCO must:

  • verify the individual meets all other eligibility criteria referenced in Section 1000, Overview and Eligibility;
  • complete the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module and submit to Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP;
  • obtain the member’s or Legally Authorized Representative’s (LAR's) signature on Form 2605, Member SK-SAI MDCP Review Signature;
    • If member refuses to sign, the MCO must document the refusal on the form;
  • obtain the individual's physician's signature on Form 2601, Physician Certification;
  • once the Medical Necessity (MN) is approved (and the SK-SAI is in the status of processed/complete), complete Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and place in the member's file;
  • complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and submit electronically to TMHP LTC Online Portal following the requirements in Appendix I; and
  • complete Section B, Waiver Assessment Report, of Form H3676 and upload to TxMedCentral.

Completion of the above activities must not cause a delay in services. If the MCO does not perform the actions listed above within 60 days from the date PSU staff uploaded Form H3676, Section A, Referral/Assessment Authorization, the MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral to advise PSU staff of any reason(s) for the delay. PSU staff will notify Managed Care Compliance & Operations (MCCO) of the delay and the reason for the delay.

The MCO must schedule and complete the SK-SAI, including the MDCP module, within 30 days of receiving Section A of Form H3676 from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP within 72 hours of completion. For the purposes of this MCO requirement, the SK-SAI is considered "complete" when the MCO has obtained the physician's signature on Form 2601, obtained the member’s or LAR’s signature, or documented the member’s or LAR’s refusal to sign Form 2605, retained Forms 2601 and 2605 in the individual's or member’s case file, and uploaded Form H3676, Section B, to TxMedCentral.

 

Physician Signature

Form 2601 is required to be completed for all initial assessments and significant change in condition assessments. This form may be requested, but is not required, for annual reassessments where no significant change in condition has been identified. The MCO must notify the member or LAR of the Form 2601 requirement. The MCO may submit Form 2601 to the applicant's physician for review and signature upon receiving Section A of Form H3676 from PSU staff but must submit no later than three business days after conducting the SK-SAI. Upon receipt of signed Form 2601, the MCO must complete and upload Form H3676, Section B, to TxMedCentral informing PSU the SK-SAI has been completed. 

If Form 2601 is not received by the MCO within five business days of the initial request to the applicant’s physician, the MCO must attempt and document at least one telephone contact per week to the applicant’s physician to obtain Form 2601. The MCO must make at least three telephone contact attempts over at least a three-week period to obtain Form 2601 before the MCO can request for PSU staff to deny the applicant.  If the MCO needs additional time to make required telephone contacts to obtain Form 2601, the MCO must upload Form H2067-MC to TxMedCentral to advise PSU staff. If at least three telephone attempts over at least a three-week period have occurred and the MCO is not able to obtain Form 2601, the MCO must upload Form H3676, Section B, to TxMedCentral requesting PSU staff deny the applicant MDCP due to MCO inability to obtain a physician’s signature on Form 2601.

 

SK-SAI Review Signature

The MCO must allow the member or LAR the opportunity to review the information gathered in the SK-SAI at the time of the home visit. The MCO must document the member’s acknowledgement and feedback on Form 2605 at the time of the home visit. If the member or LAR refuse to sign Form 2605, the MCO must document the refusal on the form at the time of the home visit. 

On Form 2605, the MCO must document any of the member’s or LAR’s comments about the information gathered in the SK-SAI, document the member’s or LAR’s request on how they want to receive a copy of the final SK-SAI that is submitted to TMHP, and the MCO service coordinator must sign to acknowledge completion of the form at the time of the home visit. 

At the time of the home visit, the MCO must educate the member or LAR on the peer-to-peer review process and offer the opportunity to request a peer-to-peer review with a physician of the member’s or LAR’s choice if the assessment results in a denial.  
Note: If the result of the assessment is a denial, the MCO is required to follow the policy in Section 6250, Denial/Termination of Medical Necessity. 

The MCO is required to complete Form 2605 for all initial assessments, reassessments and significant change in condition assessments.

The MCO must contact the member to affirm and document any changes made to the SK-SAI after the home visit. If the member or LAR has any additional comments at the time of this contact, the MCO must document that concern. 
 

Authorization of MDCP Services

A determination of MN for MDCP must be based on information collected as part of the SK-SAI. The MN determination must be made by TMHP staff before an individual can be authorized for MDCP services.

TMHP staff process the SK-SAI for an individual 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 1915(c) Medicaid waiver programs to categorize needs for an individual or member and establish the service plan cost limit. The MDCP module of the SK-SAI is used to determine the RUG.

Once TMHP staff process an SK-SAI, the MCO will receive a substantive response file with a three-digit RUG value. The RUG is alphanumeric and may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A “BC1” code indicates the SK-SAI does not have all the information necessary for TMHP staff to accurately calculate a RUG for the individual or member. Code “BC1” is not a valid RUG value to determine MDCP eligibility.

The MCO must correct the information on the SK-SAI within 14 business days of submitting the assessment that resulted in a “BC1” code. After 14 business days, the MCO must inactivate the SK-SAI and submit a new SK-SAI in its place. Information about the process of transmitting, correcting and inactivating an SK-SAI is available in Appendix I.

As a part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or RUG value assigned by TMHP. 

If the MCO is unable to establish an ISP within the cost limit assigned, the MCO must continue to provide MDCP services at the MCO’s expense and may not terminate MDCP enrollment if an individual's or member's ISP exceeds the cost limit or for any other reason (only HHSC can terminate member enrollment). When MDCP applicants or members exceed their assigned cost limit, the MCO must notify PSU staff of the MDCP program denial request of MDCP and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial is based on the inadequacy of the ISP, including both MDCP and non-MDCP services, to meet the needs of the individual within the RUG cost limit. 

Information for MDCP members exceeding the cost limit can be found in Section 3324, Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services. If a denial of services is required, the MCO must follow the denial procedure found in Section 6200, Denial/Termination of Medically Dependent Children Program.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the member does not experience gaps in authorizations and that authorizations are consistent with information in the member’s ISP.

The MCO must also adopt a methodology to track each member's monthly MDCP-related expenditures and provide an update on those expenditures to the member or LAR no less than once per month.

 

2100 Money Follows the Person

Revision 18-2; Effective September 3, 2018

 

 

 

2110 Traditional Money Follows the Person

Revision 19-1; Effective June 3, 2019

 

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aged or who have disabilities live in the most integrated setting possible. The PI Initiative is Texas' response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when the:

  • state's treatment professionals determine the placement is appropriate;
  • affected persons do not oppose such treatment; and
  • placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "a philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Texas Government Code §531.151, as amended by Senate Bill 368, 77th Legislature, Regular Session, 2001).

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with Texas Health and Human Services Commission (HHSC). For NFs, permanency planners are contracted with an external vendor. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

Additionally, in accordance with legislative direction, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another 1915(c) Medicaid waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other 1915(c) waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care (LOC), as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. Reference the STAR Kids Contract, Section 8.1.15, for further information.

The MCO must have a protocol for quickly assessing the needs of members who have or will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary personal care services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

  • determine the member’s assigned permanency planner;
  • contact the member’s assigned permanency planner within seven days of the member’s facility admission;
  • collaborate with the member, the legally authorized representative (LAR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
  • contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC's contracted permanency planner to work with the member and the member's LAR to review community based options; and
  • work with the member, the LAR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

An individual without Medicaid, and not enrolled in STAR Kids, requesting MDCP services through the MFP option must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. An individual cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. Program Support Unit (PSU) staff and the MCO must follow established time frames for processing an application for MDCP. PSU staff will authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For an individual who cannot reside in an NF for 30 days because they meet the medically fragile criteria, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP to meet the 30-day requirement. Reference Section 2120, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual.

 

2111 Non-STAR Kids Individual Residing in an NF

Revision 19-1; Effective June 3, 2019

 

For requests to transition into the community under traditional Money Follows the Person (MFP) for a non-STAR Kids member, the individual's Texas Health and Human Services Commission (HHSC)-contracted permanency planner is the designated party responsible for the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the individual and the individual's family or legally authorized representative (LAR) as part of the permanency planning process;
  • lead the development of the individual's permanency plan;
  • educate the individual and LAR on 1915(c) Medicaid waiver options, including the Medically Dependent Children Program (MDCP);
  • document the individual's choice of the 1915(c) Medicaid waiver program; and
  • educate the individual about STAR Kids, including providing information about managed care and the importance of choosing a managed care organization (MCO).

Once the individual selects a 1915(c) Medicaid waiver program, the permanency planner will contact the Interest List Management (ILM) Unit staff within two business days to notify HHSC of the individual's 1915(c) Medicaid waiver selection under MFP and update the address on file to that of the LAR, if needed.

If the individual or LAR chooses a 1915(c) Medicaid waiver program other than MDCP, ILM Unit staff will verify the individual is on the interest list for the waiver program selected and immediately release the individual from the interest list in the Community Services Interest List (CSIL) database, using the bypass code “Residing in a Nursing facility.” ILM Unit staff will forward the request to the selected 1915(c) Medicaid waiver program. The permanency planner will work with the individual, LAR, and selected 1915(c) Medicaid waiver program staff to ensure program eligibility, MCO selection, and transition to services in the community. 

Prior to the individual's discharge from the NF, the individual's selected MCO service coordinator must perform the initial SK-SAI and establish the initial ISP to reflect both MDCP services and any other identified supports, such as nursing or personal care services (PCS). The MCO initiates contact with the individual or LAR to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization.

Within 15 business days from contact with the individual or LAR, the MCO service coordinator performs the SK-SAI, including the MDCP module (record SK-SAI items Z5a and Z5b as 1 (yes) to ensure processing for MN and RUG). The MCO service coordinator must submit the SK-SAI to TMHP), following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of the assessment’s completion.

Within one business day of completing Form 2604, STAR Kids Individual Service Plan (ISP) - Service Tracking Tool, the MCO service coordinator must:

  • submit Form 2604 electronically following the requirements in Appendix I;
  • complete Section B, Waiver Assessment Report, of Form H3676; and
  • upload Form H3676 and Form H2067-MC, Managed Care Programs Communication, to TxMedCentral.

Within one business day following communication from the MEPD specialist of the individual's Medicaid eligibility, PSU staff will upload Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TXMedCentral Naming Conventions.

Within one business day prior to the individual's discharge, PSU staff generate the final Form H2065-D in the LTC Online Portal containing the service effective date and:

  • mail the final Form H2065-D to the individual; and
  • upload Form H2065-D to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must upload on TxMedCentral within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will:

  • generate Form H2065-D in the TMHP LTC Online Portal;
  • mail the original Form H2065-D to the individual; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder following the instructions in Appendix IX.

If the individual chooses to leave the NF before being determined eligible for MDCP, the MDCP case must be denied and the above steps followed.

 

2112 STAR Kids Member Residing in an NF

Revision 19-1; Effective June 3, 2019

 

When a STAR Kids member is admitted to a facility, the managed care organization (MCO) service coordinator must do the following:

  • contact the contracted Texas Health and Human Services Commission (HHSC) permanency planner within seven days of the member's admission;
  • coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process, if needed, including sharing the most recent STAR Kids Screening and Assessment Instrument (SK-SAI) tool and individual service plan (ISP);
  • perform a new SK-SAI tool for a significant change in status upon discharge, unless one is required sooner for the Medically Dependent Children Program (MDCP); and
  • update the member’s ISP to reflect changes in the SK-SAI tool, if applicable.

For requests to transition to the community under traditional Money Follows the Person (MFP) for a STAR Kids member, the member’s permanency planner is the designated party responsible for part of the process. The permanency planner will:

  • identify the holistic strengths, challenges, and needs of the member and family or legally authorized representative (LAR) as part of the permanency planning process;
  • lead the development of the member's permanency plan;
  • coordinate with the MCO service coordinator in updating the member's ISP, if applicable;
  • educate the member and LAR on 1915(c) Medicaid waiver options, including MDCP; and
  • document the member's choice of the 1915(c) Medicaid waiver program;

Within two business days of the referral from ILM Unit staff, PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to TxMedCentral in the MCO's STAR Kids folder.

The MCO initiates contact with the member or LAR to begin the assessment process within 10 business days of receipt of Form H3676.

Within 15 business days from contact with the member or LAR, the MCO service coordinator performs the SK-SAI. The MCO service coordinator must submit the SK-SAI to TMHP following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the member meets MN, the service coordinator, in conjunction with the permanency planner, member and LAR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determine a discharge date from the NF. The MCO service coordinator must submit the electronic Form 2604 to TMHP following the requirements in Appendix I within one business day of completion.

As needed, PSU staff collaborate with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays.

If within 30 days after the member’s or LAR's request to return to the community the MCO has not completed the MN process and submitted the ISP, PSU staff will email Managed Care Compliance & Operations (MCCO) to advise of the delay. PSU staff will continue to monitor TxMedCentral for receipt of Form H3676 or Form H2067-MC, Managed Care Programs Communication.

Within one business day following receipt of Form H2067-MC from the MCO, PSU staff will:

  • confirm MDCP eligibility by verifying the member:
    • is under age 21;
    • has an approved MN;
    • has an ISP with at least one MDCP service;
    • has an ISP that is within the individual’s cost limit; and
    • has an appropriate Medicaid Type of Assistance (TOA) in TIERS;
  • generate the initial Form H2065-D, Notification of Managed Care Program Services, in the TMHP LTC Online Portal; and
  • mail the initial Form H2065-D to the member.

Within one business day prior to the member’s discharge from the NF, PSU staff will:

  • generate the final Form H2065-D in the TMHP LTC Online Portal containing the service effective date;
  • mail the original Form H2065-D to the member; and
  • upload Form H2065-D to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions.

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

  • mail the original Form H2065-D to the member; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

 

2113 MDCP MFP Applications Pending Due to Delay in NF 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 an individual who has community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge from a nursing facility (NF) that goes beyond a four month period, PSU staff should keep the request for services open.

An individual who has not made living arrangements to return to the community, cannot decide when to return to the community, or has no viable plan or support system in the community should be denied the Medically Dependent Children Program (MDCP). PSU staff deny the request for services and will:

  • send Form H2065-D, Notification of Managed Care Program Services, to the individual within two business days after the end of the four calendar month pending period; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions.

 

2120 MFP Limited NF Stay Option for a Medically Fragile Individual

Revision 18-2; Effective September 3, 2018

 

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but is too medically fragile to reside in an NF for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

  • ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap));
  • renal dialysis;
  • 24-hour/day supplemental oxygen dependence;
  • total nutrition through enteral tube feeding;
  • total parenteral nutrition (TPN);
  • seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
  • documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
  • congestive heart failure requiring hospitalization and routine medication within the past six months; or
  • hospice.

An individual determined to be medically fragile and who is approved for a limited NF stay must stay at least part of two consecutive days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress that in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday because services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

 

2121 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 18-2; Effective September 3, 2018

 

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual's name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in by-passing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to by-pass the MDCP interest list:

  • STAR Kids program, if not enrolled;
  • an overview of MDCP services;
  • the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
  • the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
  • Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
  • required medical documentation must be within 12 months of the date the documentation is submitted to ILM Unit staff, from the individual’s clinical record at the physician’s office, hospital, or clinic (not from a patient portal); and
  • admission and discharge documentation from the NF will be required.

ILM Unit staff will send Form 2406 to the individual, parent, guardian or legally authorized representative (LAR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian or LAR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian or LAR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered.

 

2130 Physician Determination of Medical Fragility

Revision 19-1; Effective June 3, 2019

 

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

 

2131 PSU Procedures for an Individual Who is Approved for a Limited NF Stay and Not Enrolled in Medicaid/Without Medicaid (including an individual enrolled in CHIP)

Revision 19-1; Effective June 3, 2019

 

When an individual who is not enrolled in STAR Kids Medicaid is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, Program Support Unit (PSU) staff take steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

A STAR Kids managed care organization (MCO) must be selected prior to the limited nursing facility (NF) stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option.

Within two business days of the MCO selection, orally or in writing, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral in the MCO's STAR Kids folder.

 

2132 PSU Procedures for an Individual Who is Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids

Revision 19-1; Effective June 3, 2019

 

When an individual with Medicaid eligibility, but who is not enrolled in STAR Kids, is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, Program Support Unit (PSU) staff take steps to ensure the individual is successfully enrolled in STAR Kids and the Medically Dependent Children Program (MDCP).

A STAR Kids MCO must be selected prior to the limited NF stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option. Within two business days of the MCO selection, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral in the MCO's STAR Kids folder.

 

2133 PSU Procedures for an Individual Who is Approved for a Limited NF Stay and Currently Enrolled in STAR Kids

Revision 19-1; Effective June 3, 2019

 

When an individual who is enrolled in STAR Kids is approved for a limited nursing facility (NF) stay as outlined in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within two business days of Program Support Unit (PSU) staff assignment, PSU staff must complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating the applicant is a Supplemental Security Income (SSI) Money Follows the Person (MFP) individual. PSU staff also complete Section A, Referral/Assessment Authorization, of Form H3676 stating the member resides at home and, in the comments section, indicate this is a STAR Kids member approved for the Medically Dependent Children Program (MDCP) MFP limited NF stay option, and upload the form to TxMedCentral in the MCO's STAR Kids folder.

Within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, PSU staff must contact the applicant, parent, guardian or legally authorized representative (LAR) to ensure the applicant understands the limited NF stay must be coordinated with his or her managed care organization (MCO) service coordinator and cannot be completed until he or she is notified by the service coordinator.

 

2134 PSU and MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 19-1; Effective June 3, 2019

 

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, parent, guardian or legally authorized representative (LAR) within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral informing the individual of the decision to complete a limited NF stay. The MCO must initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, parent, guardian or LAR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the limited NF stay, and the individual or NF must present a completed paper copy of Form 3618, Resident Transaction Notice, to the MCO service coordinator or the individual's parent, guardian or LAR showing the time and date of the limited NF stay admission and discharge. Form 3618 must be received by the MCO and uploaded to TxMedCentral the same date as the NF discharge or MDCP services cannot be authorized. The MCO must explain the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must explain the individual must not proceed with the limited NF stay until he or she is authorized to do so. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) limited NF stay option funding requirements. MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

The MCO has 60 days to complete all assessments and submit required forms to Program Support Unit (PSU) staff. The MCO must complete:

  • Section B, Waiver Assessment Report, of Form H3676, noting "MFP Limited NF Stay Assessment Completed" in the comments section;
  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module;
  • the electronic Form 2604, Individual Service Plan - Service Tracking Tool; and
  • Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.

The MCO must upload Form H3676 to TxMedCentral in the MCO's STAR Kids folder and submit the electronic Form 2604 to TMHP, following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. The MCO must maintain a copy of Form 2603 in the member’s or applicant's case file.

If the MCO does not submit an ISP within 60 days after PSU staff uploaded Form H3676, Part A, PSU staff notify Managed Care Compliance & Operations by email.

For STAR Kids members accessing MDCP through the limited NF stay process for the limited NF stay, PSU staff upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, to notify the MCO of the approval pending completion of the limited NF stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited NF stay and MDCP authorization, PSU staff can approve the individual to move forward to complete the limited NF stay as long as all other eligibility criteria are met and MEPD has communicated to PSU staff that the individual is eligible for Medicaid except for the NF stay and 30 days of MDCP authorization. PSU staff upload Form H2067-MC to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, to notify the MCO to proceed with the limited NF stay. The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by uploading Form H2067-MC to TxMedCentral, following the instructions in Appendix IX.

The MCO service coordinator must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR and PSU staff. Form 3618 must be completed by the NF and submitted to the MCO service coordinator or the individual's parent, guardian or LAR on the date of discharge. The NF must understand the importance of processing and providing Form 3618 to the family and/or MCO service coordinator prior to NF discharge.

MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

Within 24 hours of the limited NF stay, the following activities must occur:

  • the MCO must notify PSU staff that the limited NF stay occurred by uploading Form H2067-MC in TxMedCentral, following the instructions in Appendix IX, requesting PSU staff approve MDCP services;
  • the MCO must upload Form 3618 to TxMedCentral (on the date of discharge) in the MCOs STAR Kids folder; and
  • PSU staff must respond to the MCO on Form H2067-MC by uploading to TxMedCentral in the MCOs STAR Kids folder, following the instructions in Appendix IX, noting that the applicant or member is pending approval of Medicaid eligibility; however, the applicant or member is eligible for MDCP services and the MCO must send an authorization to the selected provider to begin services.

Once the MCO notifies PSU staff that the applicant is authorized to receive MDCP services, within two business days, PSU staff will upload Form H2065-D, Notification of Managed Care Program Services, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, if the form was manually completed.

The MDCP effective date will be the first of the month in which the MFP individual was discharged from the NF.

MCOs must monitor the TMHP LTC Online Portal for the status of the member's ISP and to retrieve Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must upload within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff will:

  • manually complete Form H2065-D;
  • mail the final Form H2065-D to the individual; and
  • upload Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

 

2135 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 19-1; Effective June 3, 2019

 

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request that the MEPD specialist delay certification. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and fax Form H1746-A to the MEPD specialist. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending.”

If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application. Once PSU staff confirm the Medicaid denial, PSU staff must deny MDCP eligibility by:

  • manually completing Form H2065-D, Notification of Managed Care Program Services;
  • mailing the original Form H2065-D to the applicant or member; and
  • uploading Form H2065-D to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX.

MCOs must monitor the TMHP LTC Online Portal for the status of the member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian or legally authorized representative (LAR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting Interest List Management (ILM) Unit staff, as described in Section 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian or LAR requesting to reopen the Medicaid application. The MCO must upload the letter on TxMedCentral in the MCO’s STAR Kids folder. PSU staff must fax the letter with Form H1746-A marked “Application” to the MEPD specialist within two business days. The MEPD specialist’s time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to the MEPD specialist, PSU staff must request that the MEPD specialist delay certification. However, the MEPD specialist may not approve additional requests for delay in certification based on the amount of time that has passed since the original application file date.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by uploading Form H2067-MC in TxMedCentral, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian or LAR that a new Form H1200 must be completed.

Section 3000, STAR Kids Screening and Assessment and Service Planning

Section 3000, STAR Kids Screening and Assessment and Service Planning rarefyev Tue, 03/21/2017 - 09:33
Body

Revision 20-2; Effective September 1, 2020

 

3100 STAR Kids Screening and Assessment

Revision 19-1; Effective June 3, 2019

 

All children and young adults enrolled in a STAR Kids managed care organization (MCO) receive an assessment, at least annually, using the STAR Kids Screening and Assessment Instrument (SK-SAI).

The MCO must assess each member using the SK-SAI at least annually, or when the member experiences a change in condition. The assessment contains screening questions and modules that assess for medical, behavioral and functional services.

Once an MCO has completed the SK-SAI and Community First Choice (CFC), personal care services and/or Medically Dependent Children Program (MDCP) services have been determined, it is the responsibility of the MCO to communicate to the existing provider the approved service amount, duration and scope. If a new service is approved the member or legally authorized representative (LAR) should notify the MCO of the intended provider of services and the MCO shall reach out to the provider.

 

3110 Assessment of Medical Necessity for Community First Choice

Revision 18-1; Effective March 1, 2018

 

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for members with a physical disability to be eligible for Community First Choice (CFC) services. STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. A physician certification is required for all initial assessments for MN for CFC services. Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI for initial assessments for CFC. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered "complete" when the physician certification is on file in the member's case file.

If the MCO is assessing a member for CFC services for the first time, in addition to the required fields for MN, the MCO must complete the functional assessment for CFC services using the personal care assessment module (PCAM), including Section P, as well as questions in Section Z that assess for support management and emergency response services. For a member to continue to be eligible for CFC services, a determination of MN is required every 12 months. If a previous physician certification is in the member's file, a new certification is not needed.

If a member had a determination of MN approval within the last 365 days and requests CFC, the MCO completes the SK-SAI, including the PCAM and Section P, but leaves Field Z5a as marked "no" (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or his legally authorized representative (LAR). If a member meets MN and has a need for CFC services, the MCO prepares a service plan for the member and provides an authorization to the network provider of the member's or LAR’s choice.

 

3120 Assessment of Medical Necessity for the Medically Dependent Children Program

Revision 17-3; Effective September 1, 2017

 

A determination of the level of care (LOC) provided in a nursing facility (NF), referred to in STAR Kids as medical necessity (MN), is required for enrollment in the Medically Dependent Children Program (MDCP). STAR Kids managed care organizations (MCOs) must complete the required fields for a determination of MN on the STAR Kids Screening and Assessment Instrument (SK-SAI) and submit the assessment to Texas Medicaid & Healthcare Partnership (TMHP) for a determination of MN for an NF LOC.

Applicants or members coming off the MDCP interest list must be assessed for MN for eligibility for MDCP and the SK-SAI must be completed no later than 30 days following notification from Program Support Unit (PSU) staff, detailed in Section 2220, Managed Care Organization Coordination. The MCO must submit the SK-SAI to TMHP within 72 hours of completion. For the purposes of submission, an SK-SAI is only considered complete when the physician certification is on file. MCOs assessing applicants/members for MDCP services complete the SK-SAI, including the fields required for MN and the MDCP Module. The MCO must indicate yes on Field Z5a when seeking an MN determination from TMHP. A physician certification is required. Form 2601, Physician Certification, must be maintained in the member's file and must be obtained by the MCO and dated by the member's physician prior to the submission of the SK-SAI when Field Z5a is marked yes on initial assessments for MDCP.

If a member comes off the interest list who is receiving Community First Choice (CFC) services and has been determined to have MN within the last 365 days, the MCO completes the SK-SAI, including the MDCP module, but leaves Field Z5a as a “no” (indicated by a "0"). The MCO must note when the member's MN expires and arrange for a reassessment with the member and/or his legally authorized representative. A physician's certification is not required for a reassessment of MN.

Additional scenarios relating to MN determinations are available in the STAR Kids Project MCO Business Rules in Appendix I, MCO Business Rules for SK-SAI and SKI-ISP.

 

3200 Member Reassessment

Revision 20-2; Effective September 1, 2020

 

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days prior to the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid program eligibility. If there is a delay in activities, the MCO must upload Form H2067-MC, Managed Care Programs Communication, to TexMedCentral, in their designated STAR Kids folder, documenting the reason for delay. Before the end date of the annual SK-SAI, including applicable modules, the MCO must initiate an annual reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the one-year anniversary of the member's previous assessment using the SK-SAI. For members in MDCP or receiving Community First Choice (CFC) services, reassessment including posting Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, to the Long-Term Care (LTC) Online Portal, must occur no later than 30 days prior to the end date of the current ISP on file. As part of the assessment, the MCO must inform the member about Consumer Directed Services and Service Responsibility options. The MCO is expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member or member’s legally authorized representative (LAR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive personal care services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized PCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR. The MCO must also complete the NCAM at any time it determines the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

 

3210 Reassessment of Medical Necessity or Level of Care

Revision 19-1; Effective June 3, 2019

 

For members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Z5a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment and there has been no change to the member's health status. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for a psychiatric hospital or intermediate care facility serving individuals with an intellectual disability or related condition (ICF/IID), the MCO must remind the member and/or the member's legally authorized representative (LAR) to schedule a reassessment prior to the expiration of the member's LOC assessment. The MCO must work with the mental health provider assessing for psychiatric hospital LOC, or the Local Intellectual or Developmental Disability Authority (LIDDA), assessing for an ICF/IID LOC.

To ensure continuity of care, the MCO must ensure that the member is reassessed for CFC and MDCP services using the SK-SAI and the appropriate modules no later than 30 days prior to the expiration date of the member’s ISP. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

Program Support Unit (PSU) staff must ensure the member's ISP is completed annually. PSU staff:

  • check the Long Term Care (LTC) Online Portal to determine if the MCO has electronically submitted Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, before the ISP end date;
  • verify the case has an approved SK-SAI;
  • confirm ongoing Medicaid eligibility; and
  • verify the ISP is within the cost limit.

If the reassessment ISP is developed but not submitted due to the member's timely appeal of an MDCP denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and MN is denied, the MCO must notify PSU staff of the denial by uploading, within five business days of the initial MN denial date on the LTC portal, Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, asking PSU staff to manually generate Form H2065-D, Notification of Managed Care Program Services. This form is not generated in the LTC Online Portal at reassessment. PSU staff send Form H2065-D to the member and upload a copy to the appropriate MCO STAR Kids folder in TxMedCentral. See Section 3328, Reassessment Notification Requirements, for additional information.

 

3300 Member Service Planning and Authorization

Revision 19-1; Effective June 3, 2019

 

Each STAR Kids managed care organization (MCO) must create and regularly update a comprehensive person-centered individual service plan (ISP) for each STAR Kids member. Except as provided below for members receiving Medically Dependent Children Program (MDCP) services, the ISP must be completed within 90 days of completion of the initial STAR Kids Screening and Assessment Instrument (SK-SAI). The ISP must be completed within 60 days of completion of the SK-SAI for all subsequent reassessments. The MCO must ensure that all assessments are timed to prevent any lapse in service authorization or program eligibility. The purpose of the ISP is to articulate assessment findings, short and long-term goals, service needs, and member preferences. The ISP must be used to communicate and help align expectations between the member, his legally authorized representative (LAR), the MCO and key service providers. The STAR Kids Individual Service Plan (SK- ISP) must be developed through a person-centered planning process, occur with the support of a group of people chosen by the member and his LAR, on the member's behalf, and accommodate the member’s style of interaction, communication and preferences regarding time and setting. The STAR Kids ISP is for:

  • documenting findings from the SK-SAI;
  • developing a plan for services received through the STAR Kids MCO;
  • documenting services received through third party sources, such as 1915(c) waivers operated by the state;
  • identifying the member or applicant’s strengths, preferences, support needs and desired outcomes;
  • identifying what is important to the member;
  • identifying available natural supports available to the member and needed service system supports;
  • documenting the individual’s preferences for when and how to receive services;
  • identifying any special needs, requests, or considerations the MCO and/or providers should know when supporting the member; and
  • documenting the member's unmet needs.

For STAR Kids members receiving MDCP services, the ISP must establish an MDCP service plan that falls within the member’s allowable cost limit. The ISP may also be used by the MCO and the state to measure member outcomes over time. The MCO must provide a printed or electronic copy of the ISP to each member or his LAR following any significant update and no less than annually within five business days of meeting with the member or LAR. The MCO must provide a copy of the ISP to the member's providers and other individuals specified by the member or LAR. The MCO must provide the completed ISP in the format requested. The MCO must write the ISP in plain language that is clear to the member or LAR and, if requested, must be furnished in Spanish or another language.

The MCO service coordinator is responsible for examining the ISP for members receiving long term services and supports no less than three days prior to a face-to-face visit and for ensuring the document is up to date and adequately reflects the member's current health, goals, preferences and needs. The MCO is responsible for developing a strategy to ensure the ISP is closely reviewed and monitored on a regular basis for members not receiving LTSS. The member's service coordinator, or a representative of the MCO, must review and update each member's ISP with the member and his LAR no less than annually during a face-to-face visit. The MCO must complete the ISP in an electronic format compliant with state requirements. The MCO must provide the state with information from the ISP upon request.

 

3310 Service Planning

Revision 18-1; Effective March 1, 2018

 

All STAR Kids narrative individual service plans (ISPs) must be developed using person-centered practices. Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, is designed to complement the STAR Kids Screening and Assessment Instrument (SK-SAI) and where appropriate, the instructions note where information may be copied from the appropriate fields of the SK-SAI. At a minimum, Form 2603 must account for the following information:

  • A summary document describing the recommended service needs identified through the SK-SAI;
  • Covered services currently received;
  • Covered services not currently received, but that the member might benefit from;
  • A description of non-covered services that could benefit the member;
  • Member and family goals and service preferences;
  • Natural strengths and supports of the member including helpful family members, community supports or special capabilities;
  • A description of roles and responsibilities for the member, his legally authorized representative (LAR), others in the member's support network, key service providers, the member's health home, the managed care organization (MCO), and the member's school with respect to maintaining and maximizing the health and well-being of the member;
  • A plan for coordinating and integrating care between providers and covered and non-covered services;
  • Short and long-term goals for the member's health and well-being;
  • If applicable, services provided to the member through waiver programs not operated by the MCO or third-party resources, and the sources or providers of those services;
  • Plans specifically related to transitioning to adulthood for members age 15 and older; and
  • Any additional information to describe strategies to meet service objectives and member goals.

The ISP must be formed by findings from the STAR Kids screening and assessment process, in addition to input from the member, his family and caretakers, providers and any other individual with knowledge and understanding of the member's strengths and service needs who is identified by the member, the member's LAR or the MCO. To the extent possible and applicable, the ISP must also account for school based service plans and service plans provided outside of the MCO. The MCO is encouraged to request, but must not require the member, to provide a copy of the member's Individualized Education Plan (IEP).

The MCO must list Medicaid state plan services the member is receiving or is approved to receive, including service type, provider, hours per week (if applicable), begin/end date, and whether the member has chosen the Consumer Directed Services or Service Responsibility Option, if applicable. The MCO must also include a brief rationale for the services. The MCO should also list services provided by third-party resources, like Medicare or available community services. This form is updated, per the section below, and is maintained in the member's case file.

 

3311 Updates to the Individual Service Plan

Revision 19-1; Effective June 3, 2019

 

Each member's individual service plan must be updated at least annually, or sooner for situations outlined in the STAR Kids Contract, Section 8.1.39.1.

 

3320 Service Planning for Medically Dependent Children Services

Revision 19-1; Effective June 3, 2019

 

The service coordinator must work with the member and/or member's legally authorized representative (LAR) to create an individual service plan (ISP) including Medically Dependent Children Program (MDCP) services that do not exceed the member's cost limit. Only MDCP services count toward the cost limit. The cost limit is based on the member's Resource Utilization Group (RUG), which is determined based on the STAR Kids Screening and Assessment Instrument (SK-SAI). Cost limits associated with each RUG are found in Appendix VIII, RUG IPC Cost Limits.

The service coordinator documents these MDCP services on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative. Form 2603 must list the MDCP services the member is receiving or approved to receive, including service type, provider, hours per week (if applicable), begin/end date, and whether the member has chosen the Agency Option, Consumer Directed Services, or Service Responsibility Option, if applicable. The form must also include a brief rationale (i.e., why the service is needed or requested).

The list of MDCP services on Form 2603 must match the services submitted with the electronic Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. For new MDCP members coming off the interest list, the MCO completes and submits the electronic SK-ISP within 60 days of the initial notification from Program Support Unit (PSU) staff. For all current MDCP members, the MCO completes and submits the electronic SK-ISP within 60 days following receipt of a response to the SK-SAI submission. The response file from Texas Medicaid & Healthcare Partnership (TMHP) contains the determination of medical necessity and the member's RUG. The start date for the SK-ISP must be the first day of the next month. If a Medicaid eligibility determination is required, the start date of the SK-ISP is the first day of the month following a determination of Medicaid eligibility. An ISP is valid for one year.

When the member's SK-ISP is complete and within the member's established cost limit, the MCO submits the SK-ISP as Form 2604 to the TMHP Long Term Care (LTC) Online Portal or through a 278 transaction. The MCO must submit the electronic SK-ISP prior to the start date of the member's ISP and follow the instructions in Appendix I, MCO Business Rules for SK-SAI and SK-ISP. The MCO must retain a copy of Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, in the member's case file.

If the member is turning age 21 in less than one year, resulting in an ISP year that is less than 12 months, the MCO must prorate the member's cost limit. To calculate the prorated cost, the MCO must:

  • Step 1: divide the cost limit by the total number of days (365) in a year;
  • Step 2: determine the total number of days beginning with the start date of the individual service plan (ISP) and ending the last day of the month of the member's 21st birthday; and
  • Step 3: multiply the figure from Step 1 and the figure from Step 2 above to get the cost limit for the ISP period for which the member is eligible.

Example: The member's 21st birthday is July 9, the ISP start date is April 1, and the end date will be on July 31. The member's cost limit is $25,000.

  • Step 1: $25,000 ÷ 365 days = $68.49 per day
  • Step 2: The number of days per month: April = 30, May = 31, June = 30, July = 31, for a total of 122 days.
  • Step 3: $68.49 × 122 = $8,355.78

$8,355.78 is the prorated cost limit for the individual for the ISP.

 

3321 Medically Dependent Children Program Individual Service Plan Revision

Revision 17-3; Effective September 1, 2017

 

If a member and/or his legally authorized representative (LAR) requests a change to the member's Medically Dependent Children Program (MDCP) service plan, but the member has not experienced a change in condition that affects his Resource Utilization Group (RUG), and thus the cost limit, the managed care organization (MCO) must respond to the request within 14 days.

To revise a member's MDCP individual service plan (ISP) when there is no change in the member's RUG, the MCO updates Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and submits the SK-ISP to the Long Term Care Online Portal with the updated services and a revised begin date. The MCO maintains the updated Form 2603 in the member's file.

 

3322 Medically Dependent Children Program Individual Service Plan and Budget Revision

Revision 19-1; Effective June 3, 2019

 

If a member and/or his legally authorized representative (LAR), the member's provider or the managed care organization (MCO) service coordinator notify the MCO about a change in the member's condition that may affect the Resource Utilization Group (RUG), and thus the cost limit, the MCO must reassess the member within 14 days and follow the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, to document the RUG change.

Following receipt of an SK-SAI response file indicating the member's new RUG, the MCO completes a new STAR Kids individual service plan (SK-ISP) that reflects the member’s/LAR’s goals, preferences and needs within the new cost limit. The MCO must determine the cost of services provided under the original ISP and subtract that amount from the member's new cost limit to assess available funds for the remainder of the ISP period. The MCO must document how the available funds for the ISP period were determined and maintain documentation in the member's case file.

If a member will turn age 21 between the start and end date of the member's ISP, the MCO should ensure any necessary adaptive aids, minor home modifications or transition assistance are provided prior to the member's birthday. If the MCO authorizes adaptive aids, minor home modifications or transition assistance, the MCO remains responsible for payment for those services, including applicable warranties.

 

3323 Setting Aside Funds in the Medically Dependent Children Program Individual Service Plan

Revision 18-1; Effective March 1, 2018

 

Managed care organizations (MCOs) may permit a Medically Dependent Children Program (MDCP) member or his legally authorized representative (LAR) to set aside MDCP funds, within the approved cost limit, for use later in the individual service plan (ISP) period. If a member/LAR chooses to set aside funds, the MCO must document the member’s/LAR's preferences and maintain documentation in the member's case file. A member or LAR may not carry forward funds between ISP periods.

 

3324 Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services

Revision 19-1; Effective June 3, 2019

 

If the individual service plan (ISP) cost exceeds 50 percent of the Resource Utilization Group (RUG) cost limit, the managed care organization (MCO) submits via email the following documents to the Texas Health and Human Services Commission (HHSC) Utilization Review (UR) Transition/High Needs coordinator:

  • STAR Kids Screening and Assessment Instrument (SK-SAI);
  • STAR Kids Individual Service Plan (SK-ISP) and any Addendums; and
  • Medical records (nursing care plan, recent care notes, doctor's orders and nursing notes).

HHSC UR may request a clinical review of the case to consider the use of state General Revenue funds to cover costs exceeding 50 percent cost limit. If a clinical review is conducted, HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit (PSU).

Note: MCOs must not discuss with applicants, legally authorized representatives (LARs) or members, or request use of state General Revenue funds for services above the cost ceiling.

 

3325 Multiple Medically Dependent Children Program Members in the Same Household

Revision 19-1; Effective June 3, 2019

 

In some instances, multiple members receiving Medically Dependent Children Program (MDCP) services may live in the same household. In those instances, the STAR Kids managed care organization (MCO) is responsible for ensuring any MDCP services for more than one member in the same household delivered concurrently are provided in a way that protects the health and safety of each of those members.

In such cases, the MCO may allow MDCP services to be provided in a member-to-provider ratio other than one-to-one, as long as each member's care is based on his or her individual service plan (ISP) and all individuals’ needs are met.

Example: The parents of a girl and boy (sister and brother) are scheduled to receive respite services from 8 a.m. to 2 p.m. every other Saturday. The girl requires ventilator support, medication administration through a gastrostomy tube and suctioning, as needed. The boy requires assistance with ambulation, toileting and eating. In this situation, the MCO should authorize the appropriate level of staffing to meet both children’s needs to prevent provider overlap.

 

3326 Suspension of Medically Dependent Children Program Services

Revision 18-2; Effective September 3, 2018

 

A member enrolled in the Medically Dependent Children Program (MDCP), who is also receiving Community First Choice (CFC) and has a medical assistance only (MAO) eligibility for Medicaid, must receive one MDCP service monthly. In the event the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in a particular month, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file. For members who do not receive CFC and also have MAO Medicaid, the member must receive an MDCP service within the member’s individual service plan (ISP) year. In the event the member travels out of state, is admitted to a hospital or nursing facility, or is unable to receive a waiver service in the current ISP year, the STAR Kids managed care organization (MCO) must document the suspension of waiver services in the member’s case file.

The MCO must include in the documentation the:

  • dates during which services are suspended; and
  • reason for suspension.

A member may not have services suspended longer than 90 days. If a member’s services are suspended 91 days or more, the MCO must notify the Program Support Unit using Form H2067-MC, Managed Care Programs Communication, and request closure of MDCP enrollment, following procedures in Section 2000, Medically Dependent Children Program Intake and Initial Application. Closure of MDCP enrollment may result in disenrollment from STAR Kids, loss of Medicaid eligibility, or both.

 

3327 Reassessment Individual Service Provider Procedures

Revision 19-1; Effective June 3, 2019

 

Program Support Unit (PSU) staff must ensure the member's individual service plan (ISP) is authorized annually. PSU staff:

  • check the Long Term Care (LTC) Online Portal to determine if the managed care organization (MCO) has submitted Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, before the ISP end date;
  • verify the case has an approved Star Kids Screening and Assessment Instrument (SK-SAI);
  • confirm ongoing Medicaid eligibility; and
  • verify the ISP is within the cost limit.

If the reassessment ISP is not submitted due to the member's timely appeal of a Medically Dependent Children Program (MDCP) denial, the individual's services will continue using the existing ISP until a decision is received from the hearing officer. Once the hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

 

3327.1 Process for Reviewing the Individual Service Plan Expiring Report

Revision 20-2; Effective September 1, 2020

 

Program Support Unit (PSU) staff and managed care organizations (MCOs) will review the Individual Service Plan (ISP) Expiring Report for the Medically Dependent Children Program (MDCP) on a monthly basis to ensure annual reassessments are conducted timely. The ISP Expiring Report lists the MDCP members with ISPs that will expire within the next 90 days.

PSU staff will schedule a monthly conference call with each MCO.

The MCOs must generate the ISP Expiring Report in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal five business days prior to the monthly conference call with PSU staff. The MCO must provide a status update for all MDCP members who have ISPs expiring within the next 45 days. Although the report shows all ISPs expiring within 90 days, only those expiring within 45 days require a status update.

 

3328 Reassessment Notification Requirements

Revision 19-1; Effective June 3, 2019

 

If the member continues to meet waiver requirements, Program Support Unit (PSU) staff do not send Form H2065-D, Notification of Managed Care Program Services, at the reassessment as notification of continuing services.

If the member does not meet waiver requirements, PSU staff must, within two business days of receiving Form H2067-MC, Managed Care Programs Communication, from the managed care organization (MCO):

  • send Form H2065-D to the member indicating why the case is being terminated;
  • terminate the individual service plan (ISP) through the Long Term Care (LTC) Online Portal; and
  • manually generate Form H2065-D and upload it to the MCO's STAR Kids folder in TxMedCentral.

If the member files a state fair hearing within the 10-day adverse action period (refer to Section 6100, Ten-Day Adverse Action Notification), within two business days of notification PSU staff must:

  • upload Form H2067-MC in TxMedCentral to the MCO's STAR Kids 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); and
  • extend the end date of the current ISP in the LTC Online Portal an additional four calendar months.

PSU staff carry out the decision within 10 days of receiving the fair hearings officer's decision.

 

3400 Member Transfers

Revision 18-1; Effective March 1, 2018

 

 

 

3410 Transfer from One Managed Care Organization to Another

Revision 20-2; Effective September 1, 2020

 

A member or their legally authorized representative (LAR) may request a plan change to another managed care organization (MCO) 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 or their LAR wants to change from one MCO to another MCO, the member or LAR may submit a request in one of the following ways:

  • by logging into YourTexasBenefits.com; or
  • by contacting the state-contracted enrollment broker:
    • by phone at 1-800-964-2777;
    • by fax at 1-855-671-6038; or
    • by mail at:
      HHSC
      P.O. Box 149023
      Austin TX 78714-9023

Note: Adoption Assistance or Permanency Care Assistance (AAPCA) members should contact the state’s enrollment broker to request transfer.  

If the member requests to change MCOs on or before the monthly state cut-off date, the plan change will be effective on the first day of the month following the change request. If the member requests to change MCOs after the monthly state cut-off date, the change will be effective the first day of the second month following the change request. Note: The state cut-off date is not always on the same day every month, but typically occurs mid-month.

Examples:

Cutoff Date – April 12

  • If the member requests a transfer on April 9, it will take effect on May 1.
  • If the member requests a transfer on April 20, it will take effect on June 1.

For more details, see the Uniform Managed Care Manual, Chapter 3.4, Attachment C to the Medicaid Managed Care Member Handbook Required Critical Elements.

 

MCO Transfer Activities (Required Communication Between the Gaining and the Losing MCO)

HHSC Program Enrollment & Support prepares and sends a Monthly Plan Changes report to Program Support Unit (PSU) staff. The report gives a list of STAR Kids program members who have transferred MCOs from the previous month. PSU staff sends the report to the regional PSU offices to confirm system changes and makes any necessary updates or transfers. The MCO can find the member-specific plan changes in their Monthly Enrollment (P34) file in TxMedCentral.

To prevent duplication of activities when a member changes MCOs, the former (or losing) MCO must provide the receiving (or gaining) MCO with information concerning the results of the MCO’s identification and assessment upon the gaining MCO's request.

Within five business days of receiving the list of members changing MCOs, the gaining MCO must request any documentation in the member's case file from the losing MCO, such as the member's Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, existing prior authorizations, and minor home modifications (MHMs) and adaptive aids (AA) limits reached.

Within five business days of receiving the request, the losing MCO must provide the requested documents to the gaining MCO. The gaining MCO must coordinate with the losing MCO to ensure a seamless transition. The gaining MCO must contact the losing MCO for any additional information maintained in the member's case file that may be required. If the gaining MCO experiences issues obtaining this information, the MCO must notify the Managed Care Compliance and Operations (MCCO) Health Plan manager.

 

Gaining MCO Responsibilities for Continuity of Care

The gaining MCO is responsible for service delivery from the first day of enrollment. Within 10 business days of enrollment of the new member, the gaining MCO must contact the member to discuss services needed by the member. For continuity of care, this includes authorizations, assistance with finding in-network providers, additional assessments, and pending delivery of AAs, MHMs or transition assistance. A home visit must be scheduled to conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) if the member is due for a new assessment, has experienced a significant change in condition, or if otherwise deemed necessary by the gaining MCO. The gaining MCO must adhere to all rules for SK-SAI processing related to member transfers outlined in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The gaining MCO must provide services and honor authorizations included in the prior ISP until the member requires a new assessment or until the gaining MCO is able to complete its own SK-SAI, update the ISP, and issue new service authorizations. The gaining MCO must allow the member to continue to receive services with their existing provider and allow an out-of-network authorization to ensure the member’s condition remains stable and services are consistent to meet the member’s need until a network provider can be located and accessed.

 

3420 Member Transfer from Waiver Program to Medically Dependent Children Program

Revision 19-1; Effective June 3, 2019

 

If a STAR Kids member in another Medicaid waiver program comes up on the interest list for MDCP, 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 an MDCP assessment. All attempted contacts with the member or encountered delays must be documented.

PSU staff:

  • contact the member and explain MDCP services; and
  • send a copy of the STAR Kids managed care organization (MCO) provider directories and comparison chart to the 1915(c) waiver member.

Within two business days of notification of the MCO selection by the waiver member, PSU staff complete Section A of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload it in the MCO's STAR Kids folder on TxMedCentral, using the appropriate naming convention.

The MCO completes:

  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module;
  • Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, and submits it electronically in the Long Term Care (LTC) Online Portal or through a 278 transaction; and
  • Form H3676, Section B and send to PSU staff, once the SK-SAI is complete.

If the information from the MCO is not received within 60 days after the assessment is authorized, PSU staff email the assigned health plan manager as notification the time frame for completing the individual service plan (ISP) was not met.

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

If eligibility for MDCP is denied or the individual decides not to accept MDCP services, PSU staff:

  • generate Form H2065-D, Notification of Managed Care Program Services, in the LTC Online Portal; and
  • mail the original Form H2065-D to the 1915(c) waiver individual, with the explanation that this finding does not affect eligibility for the service the individual is currently receiving.

The MCO must monitor the LTC Online Portal to check the status of the member's ISP and to retrieve Form H2065-D and file in the MCO’s case file.

If eligibility is approved and the individual chooses to accept MDCP services, the individual is enrolled in MDCP the first day of the next month. Within two business days of determining the start of care date for MDCP services, PSU staff:

  • generate Form H2065-D in the LTC Online Portal; and
  • mail the original Form H2065-D to the 1915(c) waiver individual.

PSU staff must coordinate with staff and providers, as appropriate, to ensure the current 1915(c) waiver services end the day before enrollment in MDCP. The MCO must monitor the LTC Online Portal for the status of the member's ISP and to retrieve Form H2065-D and file in the MCO’s case file.

 

3430 Member Transfer from MDCP to Another Waiver

Revision 19-1; Effective June 3, 2019

 

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may be on an interest list for another Medicaid program such as Community Living Assistance and Support Services (CLASS), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD) or Texas Home Living (TxHmL). The Texas Health and Human Services Commission (HHSC) informs the managed care organization (MCO) that a member receiving MDCP services has come to the top of the interest list for another program and is assessed as eligible for that program.

The service coordinator or case manager must contact Program Support Unit (PSU) staff via Form H2067-MC, Managed Care Programs Communication, to assist in coordinating the end of MDCP services the day prior to the member's enrollment in the new program. PSU staff must coordinate with the member's MCO about the end of MDCP services and the member's transition to another waiver. The member remains in the same STAR Kids MCO he is currently enrolled in for his state plan services.

PSU staff:

  • move the interest list with an "assessment requested" notation;
  • close the MDCP release in the CSIL system effective the date of the notification from the MCO informing of the member's decision to transfer to another waiver program; and
  • send Form 2442, Notification of Interest List Release Closure, to the member notifying of the MDCP closure. If the CLASS or other waiver program application is denied, Form 2442 will instruct the member to contact the Interest List Management (ILM) Unit if he or she wishes to apply for MDCP. When the member contacts ILM Unit, he or she will be reinstated on the MDCP interest list.

 

3440 Member Transfer from Community Services to STAR Kids

Revision 19-1; Effective June 3, 2019

 

Program Support Unit (PSU) staff must coordinate the termination of Community Care for the Aged and Disabled (CCAD) services with the Community Care Services Eligibility (CCSE) case worker so that the individual does not experience a break in services and does not receive concurrent services through another waiver or CCAD service.

For individuals entering STAR Kids through the Medically Dependent Children Program (MDCP), PSU staff coordinate the termination of CCAD services with the CCSE case worker. This ensures the individual does not experience a break in services and does not receive concurrent services through CCAD service.

CCAD services are terminated by the CCSE case worker no later than the day prior to MDCP enrollment. This is crucial since no MDCP member may receive CCAD and MDCP services on the same day.

 

3500 Member Transition to Adult Programs

Revision 18-1; Effective March 1, 2018

 

Per the STAR Kids Managed Care Contract, all STAR Kids members begin transition services when they are age 15 and periodically meet with a transition specialist to plan their transition to adulthood. Members who receive Medically Dependent Children Program (MDCP) services, Private Duty Nursing (PDN), Community First Choice (CFC) or Personal Care Services (PCS) and are transitioning to adult programs may apply for services through STAR+PLUS, including STAR+PLUS Home and Community Based Services (HCBS) program, in order to continue receiving community-based services and avoid institutionalization beginning the first day of the month following their 21st birthday.

 

3510 Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC

Revision 18-1; Effective March 1, 2018

 

Possible waiver and service combinations the member may be receiving prior to transition:

  • Medically Dependent Children Program (MDCP) only;
  • Private Duty Nursing (PDN) only;
  • Prescribed Pediatric Extended Care Center (PPECC) services only;
  • MDCP with either or both of the following services:
    • Personal Care Services (PCS);
    • PDN/PPECC;
  • MDCP with Community First Choice (CFC) services;
  • PDN/PPECC with PCS; and
  • PDN/PPECC with CFC services.

 

3511 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 member receiving services from the Medically Dependent Children Program (MDCP), Private Duty Nursing (PDN) or Prescribed Pediatric Extended Care Center (PPECC) services, the following process begins.

Each quarter, Texas Health and Human Services Commission (HHSC) Utilization Review (UR) provides a copy of the MDCP PDN Transition Report, which lists individuals enrolled in STAR Kids and receiving MDCP and/or PDN/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 (PSU) supervisor; and
  • UR unit for the Intellectual and Developmental Disability (IDD) 1915(c) waivers.

The managed care organization (MCO) identifies all members turning age 21 within the next 12 months and schedules a face-to-face visit with the member and the member's available supports, including the legally authorized representative (LAR), if applicable, to initiate the transition process.

During the home visit with the member/LAR/supports, the MCO must present an overview of the STAR+PLUS program, including the STAR+PLUS HCBS program and the changes that will take place the first of the month following the member's 21st birthday. The transition activity points to be discussed at the visit by the MCO can be found in Appendix VI, STAR Kids Transition Activities, Transition Activities at Age 20.

The STAR Kids MCO:

  • follows up with the member or the support person every 90 days during the year before the member turns age 21 to ensure transition activities specified in Appendix VI, STAR Kids Transition Activities, have been completed; and
  • notifies HHSC UR via email at HHSC_UR_High_Needs_CCR@hhsc.state.tx.us indicating the member appears to meet the criteria in the STAR+PLUS Handbook, Appendix XIV, Determination of High Needs Status for the STAR+PLUS HCBS Program. The notification must include the number of PDN hours currently authorized.

PSU staff for STAR+PLUS HCBS program:

  • monitor the MDCP PDN Transition Report and identify all individuals referenced in Section 3510, Procedures for Children Transitioning from STAR Kids Receiving MDCP, PDN or PPECC, turning age 21 in 12 months and not enrolled in one of the following IDD 1915(c) 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).

 

3512 STAR+PLUS Transition Activities

 

Revision 18-1; Effective March 1, 2018

 

Program Support Unit (PSU) staff for the STAR+PLUS Home and Community Based Services (HCBS) program will follow the STAR+PLUS enrollment guidelines as outlined in the STAR+PLUS Handbook, Section 3420, Individuals Transitioning to an Adult Program.

 

3513 Intrapulmonary Percussive Ventilator Benefit

Revision 19-1; Effective June 3, 2019

 

Intrapulmonary Percussive Ventilator (IPV) is not currently a benefit of Texas Medicaid, but Texas Health and Human Services Commission (HHSC) has approved IPVs in limited circumstances based on medical necessity (MN) criteria under the Comprehensive Care Program (CCP) on a case-by-case basis.

IPV is not a benefit of Texas Medicaid, with the following exceptions:

  • Children and young adults who have been approved for and are currently utilizing IPV in traditional Medicaid will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of the child/young adult when he transitions to a STAR Kids managed care organization (MCO).
  • When a member turns age 21 and transitions into STAR+PLUS, young adults who have been approved for and are currently utilizing IPV will be allowed to continue using IPV if it is deemed to have a beneficial impact on the health of a young adult.  The member will not be subjected to an abrupt removal of equipment. The member will continue to receive ongoing treatment until the final decision is made, on a case-by-case basis, with thorough review and documentation by the MCO and explicit approval by HHSC administration.
  • STAR Kids MCOs will address a new request for IPV on a case-by-case basis based on MN criteria for the member.

Section 4000, STAR Kids Community Services

Section 4000, STAR Kids Community Services rarefyev Tue, 03/21/2017 - 14:55
Body

Revision 21-1; Effective April 1, 2021

 

4010 Outline

Revision 19-1; Effective June 3, 2019

 

This section outlines the delivery of STAR Kids community long term services and supports. Sections 4100-4520 describe Medicaid state plan long term services and supports, assessment and reassessment requirements, and provider requirements.

Sections 4600-4922 describe services available to members receiving Medically Dependent Children Program (MDCP) services, service requirements and limitations, and provider requirements.

 

 

4100 Community First Choice

Revision 19-1; Effective June 3, 2019

 

Community First Choice (CFC) is a group of services delivered under the authority of §1915(k) of the Social Security Act. CFC is authorized by federal regulations governing home and community based services. Therefore, the settings in which CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) §441.301(c)(4) and §441.710 respectively. Permissible home and community based settings include member homes, apartment buildings and non-residential settings. Community based settings exclude:

  • nursing facilities;
  • hospitals providing long term care services;
  • inpatient psychiatric facilities;
  • intermediate care facilities for individuals with an intellectual disability or related conditions (ICF-IID); or
  • settings on the grounds of, adjacent to, or with the characteristics of, an institution.

Individuals served in provider owned and controlled residential settings are also excluded from CFC because their provider rate includes payment for the provision of CFC-like services, and to provide CFC would be duplicative.

In addition, assessment for CFC services and the development of a member's service plan must be person-centered, per 42 CFR §441.535 and §441.540. STAR Kids managed care organizations may not require CFC providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for CFC services.

 

 

4110 Community First Choice Eligibility

Revision 19-1; Effective June 3, 2019

 

Eligibility for Community First Choice (CFC) requires a STAR Kids member to:

  • be Medicaid eligible;
  • meet the level of care provided in a hospital nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID), or an institution providing psychiatric services; and
  • have an assessed functional need for CFC services.

All STAR Kids members are Medicaid eligible. Members whose eligibility is established for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per § 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month, as these members meet eligibility for services in an institution providing psychiatric care and an NF, respectively.

A member may not be authorized to receive both Personal Care Services (PCS) and CFC services at the same time. Members eligible for CFC will receive personal assistance services (CFC-PAS) and habilitation (HAB), through CFC in lieu of PCS.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver provider and are not eligible to receive CFC through managed care:

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

 

 

4111 Determining Institutional Level of Care

Revision 19-1; Effective June 3, 2019

 

Nursing Facility (NF) Level of Care

For STAR Kids members, the STAR Kids Screening and Assessment Instrument (SK-SAI) contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP) to determine on behalf of the Texas Health and Human Services Commission (HHSC) if a member meets medical necessity (MN) for the level of care (LOC) provided in a hospital or NF. Questions within the SK-SAI which identify a need for Community First Choice (CFC) personal assistance services (PAS)/habilitation (HAB) services are within the Core, Personal Care Assessment (PCAM) and Nursing Care Assessment (NCAM) modules of the SK-SAI. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of MN for CFC, the MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires NF services or alternative community based services under the supervision of a physician.

Further information about the medical necessity determination process for CFC may be found in Section 3110, Assessment of Medical Necessity for Community First Choice.

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF-IID) Level of Care

For STAR Kids applicants and members, the MCO must contact the Local Intellectual or Development Disability Authority (LIDDA) to conduct an assessment to determine whether a STAR Kids applicant or member meets the LOC provided by an ICF-IID. In addition to the Intellectual Disability or Related Condition (ID/RC) assessment, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a STAR Kids applicant or member does not have one on file. The LIDDA must submit the DID information to HHSC for a determination of ICF-IID LOC. HHSC notifies both the LIDDA and the STAR Kids applicant or member's MCO once an ICF-IID LOC determination has been made. If a STAR Kids applicant or member meets the LOC provided in an ICF-IID, the MCO completes the CFC functional assessment if the applicant or member requests CFC services.

Psychiatric Facility Level of Care

For STAR Kids applicants and members, the MCO may contact a comprehensive provider of mental health rehabilitative services or a local mental health authority (LMHA) to conduct the Children and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and a licensed practitioner determines whether the STAR Kids applicant or member meets an inpatient psychiatric facility LOC. If the STAR Kids applicant or member meets that LOC provided in a psychiatric facility, or receives services through the Youth Empowerment Services program, the MCO conducts the CFC functional assessment if the member requests CFC services.

 

 

4120 Community First Choice Services

Revision 19-1; Effective June 3, 2019

 

Community First Choice (CFC) services include personal assistance services (PAS), habilitation (HAB), emergency response services (ERS) and support management.

 

 

4121 Community First Choice Personal Assistance Services

Revision 19-1; Effective June 3, 2019

 

Community First Choice (CFC) personal assistance service (PAS) provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision and/or cueing. Assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. CFC PAS include:

  • Non-skilled assistance with the performance of ADLs and IADLs;
  • Household chores necessary to maintain the home in a clean, sanitary and safe environment;
  • Escort services, which consist of accompanying, but not transporting, and assisting a member to access services or activities in the community; and
  • Assistance with health-related tasks. Health-related tasks, in accordance with state law, include tasks delegated by a registered nurse (RN), health maintenance activities and extension of therapy. An extension of therapy is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow-up to therapy sessions. If appropriate, the member's attendant can assist the member in accomplishing such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) model, the member or legally authorized representative determines health-related tasks without a nurse assessment, in accordance with §531.051(e) of the Texas Government Code and §225.4 of the Texas Administrative Code.

CFC PAS is the same service (i.e., attendant care) as Personal Care Services (PCS). The only difference is the level of care (LOC) requirement and how the service is billed. Information used to build a plan of care for CFC PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by certain items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC PAS if the member meets CFC level of care criteria.

 

 

4122 Community First Choice Habilitation

Revision 19-1; Effective June 3, 2019

 

Community First Choice (CFC) habilitation assists members with acquisition, maintenance, and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is provided to allow a member to reside successfully in a community setting by assisting the member to acquire, retain and improve self-help, socialization, and daily living skills or assisting with and training the member on ADLs and IADLs. Personal assistance may be a component of CFC habilitation for some members. CFC habilitation services include training, which is interacting face-to-face with a member to train the member in activities, such as:

  • self-care;
  • personal hygiene;
  • household tasks;
  • mobility;
  • money management;
  • community integration, including how to get around in the community;
  • use of adaptive equipment;
  • personal decision-making;
  • reduction of challenging behaviors to allow members to accomplish ADLs, IADLs and health-related tasks; and
  • self-administration of medication.

Information used to build a plan of care for CFC habilitation may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM) in Section P. This section of the PCAM should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for emergency response services (ERS).

 

 

4123 Community First Choice Emergency Response Service

Revision 19-1; Effective June 3, 2019

 

Community First Choice (CFC) emergency response services (ERS) is designed to assist individuals who live alone, are alone for large parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, to a member's emergency. This service is not routinely authorized for members who are minors.

ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use CFC-ERS for CFC-ERS to be authorized.

The need for ERS is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Z.

 

 

4124 Community First Choice Support Management

Revision 17-1; Effective June 1, 2017

 

Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model.

 

Need for support management is assessed using the STAR Kids Screening and Assessment Instrument, Section Z.

 

 

4130 Community First Choice Assessment and Authorization

Revision 17-1; Effective June 1, 2017

 

 

 

 

4131 Assessment for a Nursing Facility Level of Care

Revision 19-1; Effective June 3, 2019

 

Nursing facility level of care (LOC) for members seeking Community First Choice (CFC) services is established using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member's eligibility for NF services according to the Texas Administrative Code §19.101(88) definition of “medical necessity.”

The MCO must indicate yes in Field Z5a to notify TMHP that an MN determination is required. TMHP's determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines that the member does not meet MN, the member is not eligible to receive CFC through the nursing facility LOC. This does not preclude the member or MCO from seeking determination of a different institutional LOC. If TMHP determines that that the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the nursing facility LOC.

 

 

4131.1 Reassessment for a Nursing Facility Level of Care

Revision 19-1; Effective June 3, 2019

 

To ensure continued eligibility for Community First Choice services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Z5a to notify Texas Medicaid & Healthcare Partnership (TMHP) that a medical necessity (MN) determination is required. Form 2601, Physician Certification, is not required for annual MN reassessments if the member's file contains the form for a previous assessment. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.

 

 

4132 Assessment for an Intermediate Care Facility Level of Care

Revision 19-1; Effective June 3, 2019

 

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member's named service coordinator’s contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability (DID) and ID/RC, the LIDDA submits the assessment for a determination of level of care to the state. The Texas Health and Human Services Commission (HHSC) informs both the LIDDA and MCO of the determination. If a member is determined to not meet the level of care provided in an intermediate care facility (ICF), the MCO is responsible for notifying the member through the established denial process. HHSC attends the fair hearing if one is requested.

If a member meets an ICF level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues Community First Choice services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

 

 

4132.1 Reassessment for an Intermediate Care Facility Level of Care

Revision 19-1; Effective June 3, 2019

 

Ninety days prior to the expiration of the member's level of care assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility (ICF) level of care. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an Intermediate Care Facility Level of Care, for all reassessments.

If a member continues to meet an ICF level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

 

 

4133 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 19-1; Effective June 3, 2019

 

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to a comprehensive provider agency that can deliver mental health targeted case management and mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member's age. Based on an algorithm, the assessment determines the member's level of care (LOC). A member may be deviated into a higher or lower LOC, based on his clinical judgement and member preference. A licensed practitioner of the healing arts (LPHA) must review the member’s diagnosis at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member's CANS or ANSA is valid for 12 months.

Members enrolled in the Youth Empowerment Services (YES) waiver meet a psychiatric institutional level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their MCO for functional eligibility for CFC services at any time while enrolled in YES.

 

 

4133.1 Reassessment for an Institution Providing Psychiatric Services Level of Care

Revision 19-1; Effective June 3, 2019

 

Assessment of a psychiatric institutional level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member's CFC service plan, the managed care organization (MCO) must refer the member to the local mental health authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet a psychiatric institutional level of care, the MCO may conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity for a nursing facility LOC. If the MCO believes the member will not meet medical necessity and does not have an intellectual or developmental disability, the MCO must notify the member or his representative of the denial for CFC services. The member may be eligible for personal care services (PCS), if functionally necessary.

 

 

4140 Functional Assessment for Community First Choice Services

Revision 19-1; Effective June 3, 2019

 

Functional need for Community First Choice (CFC) services is primarily established by Sections J, K, L, M, N, O, and P of the STAR Kids Screening and Assessment Instrument (SK-SAI) which form the Personal Care Assessment Module (PCAM). This module contains assessment questions for the attendant care (CFC PAS) and habilitation services available through CFC. The following questions/information in the SK-SAI core module are triggers for the PCAM and may indicate the member has functional need for CFC services:

  • A personal care aide is provided in a school or day program;
  • The caregiver, member or others are concerned about the member's developmental status or decline from baseline related to self-care (dressing, bathing, using toilet, self-care);
  • Decline in functional status as compared to 90 days ago or since the last assessment;
  • Instrumental activity of daily living (IDAL) self-performance;
  • Activity of daily living (ADL) self-performance;
  • The member is moderately or severely impaired regarding cognitive skills for daily decision making;
  • The member requires diet modification to swallow solid food;
  • The member requires modifications to swallow liquids;
  • The member received personal care services (PCS), attendant care or a home health aide in the last 30 days; and/or
  • The member or his legally authorized representative (LAR) requests an assessment for CFC or PCS.

If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, O, and P) to determine attendant care needs. Section P should only be completed if the member is specifically seeking CFC services. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of CFC services. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

If the MDCP applicant or member does not agree to the CFC service plan, he or she may file an appeal with the MCO.

If the STAR Kids applicant or member does not agree to the CFC service plan or refuses CFC services for psychiatric facility level of care, the MCO must notify the LIDDA within 10 business days of the member ending CFC services.

 

 

4140.1 Reassessment of Functional Need for Community First Choice

Revision 19-1; Effective June 3, 2019

 

The need for and the amount and duration of Community First Choice services must be reassessed every 12 months, or when requested by the member or as needed due to a change in the member's health condition or living situation.

 

 

4200 Personal Care Services

Revision 19-1; Effective June 3, 2019

 

Personal care services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through age 20. PCS is considered medically necessary when a member requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member's disability or chronic health condition. The member's disability or chronic health condition must be substantiated by a physician statement of need. STAR Kids managed care organizations (MCO) may not require PCS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typically developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a member's responsible adult must perform ADLs, IADLs and HMAs on behalf of the individual to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member's physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to assist the individual in performing a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that inhibits the individual’s ability to accomplish ADLs, IADLs or HMAs.

PCS includes:

  • Assistance with ADLs and IADLs;
  • Nurse-delegated tasks and HMAs within the scope of PCS, as permitted by program policy and 22 Texas Administrative Code Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions); and
  • Hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task.

The amount and duration of PCS is determined by the MCO and must take the following into account:

  • Whether the member has a physical, cognitive or behavioral limitation related to a disability or chronic health condition that inhibits the member's ability to accomplish ADLs or IADLs;
  • The member's caregiver's need to sleep, work, attend school and meet his own medical needs;
  • The member's caregiver's legal obligation to care for, support, and meet the medical, educational and psychosocial needs of other members of the household;
  • The member's caregiver's physical ability to perform PCS;
  • Whether requiring the member's caregiver to perform PCS will put the member's health or safety in jeopardy;
  • The time periods during which PCS tasks are required by the member, as they occur over the course of a 24-hour day and a seven-day week;
  • Whether or not the need to assist the family in performing PCS on behalf of the member is related to a medical, cognitive or behavioral condition that results in a level of functional ability that is below that expected of a typically developing child of the same chronological age; and
  • Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210 that follows.

PCS may be authorized to support a member's primary caregiver(s) but may not be authorized to supplant a member's natural support, nor to provide a member's total care. PCS may be authorized in an individual or group setting including, but is not limited to the:

  • member's home;
  • home of the primary or other caregiver;
  • member's school;
  • member's day care facility; or
  • community setting in which the member is located.

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, is required to meet the member's personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation may be submitted to the MCO with documentation of medical necessity.

PCS may not be authorized in a hospital, nursing facility, institution providing psychiatric care, or an intermediate care facility for individuals with intellectual or developmental disabilities (ICF-IID).

PCS may not be used as respite, child care, or for the purposes of restraining a member. PCS may be authorized in a group setting.

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver program and are not eligible to receive PCS through the MCO:

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

 

 

4210 Assessment for Personal Care Services

Revision 17-1; Effective June 1, 2017

 

Sections J, K, L, and M of the STAR Kids Screening and Assessment Instrument (SK-SAI) form the Personal Care Assessment Module (PCAM). This module contains assessment questions for personal care services (PCS). The following questions in the SK-SAI core module are triggers for the PCAM and may indicate the member requires PCS:

  • A personal care aide is provided in a school or day program;
  • The caregiver, member or others are concerned about the member's developmental status or decline from baseline related to self-care (dressing, bathing, using toilet self-care);
  • Decline in functional status as compared to 90 days ago or since the last assessment;
  • Instrumental activity of daily living (IADL) self-performance;
  • Activity of daily living (ADL) self-performance;
  • The member is moderately or severely impaired regarding cognitive skills for daily decision making;
  • The member requires diet modifications to swallow solid food;
  • The member requires modifications to swallow liquids;
  • The member received PCS, attendant care or a home health aide in the last 30 days; and/or
  • The member or his legally authorized representative requests an assessment for Community First Choice (CFC) or PCS.

If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, and O) to determine attendant care needs. Section P should not be completed if the member is only seeking PCS and not CFC. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PCS. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.

 

 

4211 Reassessment for Personal Care Services

Revision 17-1; Effective June 1, 2017

 

The need for and the amount and duration of personal care services (PCS) must be reassessed every 12 months, or when requested due to a change in the member's health or living condition. The managed care organization must obtain a new physician statement of need to substantiate the member's continued need for PCS upon each annual reassessment.

 

 

4220 Personal Care Services Providers

Revision 19-1; Effective June 3, 2019

 

Personal care services (PCS) must be provided by an individual who:

  • is 18 years of age or older;
  • is an attendant who:
    • is an employee of a provider organization licensed as a Home and Community Support Services Agency (HCSSA) or organizations licensed to provide home health services or personal assistance services; or
    • is employed by the member or his legally authorized representative (LAR) through the Consumer Directed Services (CDS) option.
  • has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member or the member's responsible adult or LAR acting as employer through the CDS option.
  • is not the responsible adult of the member if the member is under the age of 18; and
  • is not the spouse of the member.

 

 

4300 Private Duty Nursing

Revision 20-2; Effective September 1, 2020

 

Medicaid managed care organizations (MCOs) must follow all federal and state laws and rules and the provisions of the Texas Medicaid Provider Procedures Manual (TMPPM) and their contracts regarding Private Duty Nursing (PDN) services.

PDN services are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. PDN services are nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing (SN) visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) services.

PDN is a THSteps-CCP benefit in accordance with the Code of Federal Regulations, Title 42, §440.80, relating to PDN services, and §440.40(b), relating to Early Periodic Screening, Diagnostic and Treatment (EPSDT) services. THSteps-CCP is an expansion of the EPSDT service as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989, which requires all states to provide all medically necessary treatment for correction or amelioration of physical or mental illnesses and conditions to THSteps eligible clients when federal financial participation (FFP) is available, even if the services are not covered under the Medicaid state plan.

MCOs must follow all EPSDT requirements, including the provision of PDN services, for STAR Kids members.

State rules governing PDN are found at Texas Administrative Code (TAC) Title 1, Part 15, Chapter 363, Subchapter C. These rules and related policies, including rules and policy related to prior authorization, apply to HHSC or its designees, which include MCOs (see 1 TAC §363.301(c), §363.303(6), and §363.311(b)). MCOs are required to follow all policies governing PDN services in the TAC, as well as the latest edition of the TMPPM. Texas Medicaid’s THSteps-CCP PDN policy may be found in Section 4 of the TMPPM’s Home Health and Private Duty Nursing Services Handbook. Additional Information related to the THSteps-CCP Program may be found in Section 2 of the TMPPM’s Children’s Services Manual.

These rules and TMPPM policy provisions are the result of the final settlement agreement in the Alberto N., Et. Al. v. Albert Hawkins, Et. Al. lawsuit.

Because PDN is a Texas Medicaid THSteps-CCP service, the rules and related policies cited above apply directly to the STAR Kids program. See 8.1.2 Covered Services of Attachment B-1 of the STAR Kids Contract. MCOs must ensure that if their internal policy and procedure manuals contain language and guidance for processing PDN service requests, these documents are updated to align with all federal and state laws and rules, as well as the Texas Medicaid medical policy guidance available in the latest version of the TMPPM. See 7.02 MCO responsibility for compliance with laws and regulations of Attachment A of the STAR Kids Contract.

 

 

4310 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

 

Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400 that follows, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service delivery area. A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual's medical condition or the authorized hours are not commensurate with the individual's medical needs. Per §363.209 (c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, the Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. The fee-for-service Nursing Addendum to the Plan of Care for PPECCs and PDN includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual's medical needs. The PDN provider would be notified by the managed care organization of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care for the individual. The service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.

 

 

4400 Prescribed Pediatric Extended Care Centers

Revision 20-2; Effective September 1, 2020

 

Prescribed Pediatric Extended Care Center (PPECC) services is a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP) for STAR Kids members who meet the following medical necessity criteria for admission:

  • Eligible for THSteps-CCP;
  • Age 20 years or younger;
  • Have an acute or chronic condition that requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
  • Considered to be a medically dependent or technologically dependent member;
  • Stable for outpatient medical services, and does not present a significant risk to other individuals or personnel at the PPECC;
  • Requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:
    • deterioration of a chronic condition;
    • loss of function;
    • imminent risk to health status due to medical fragility; or
    • risk of death;
  • Has a prescription for PPECC services signed and dated by an ordering physician who has personally examined the member within 30 calendar days prior to admission and reviewed all appropriate medical records;
  • Has consent for the member's admission to the PPECC signed and dated by the member or the member's responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of private duty nursing (PDN) by the member or member's responsible adult in both managed care and non-managed care service delivery systems; and
  • Resides with the responsible adult and does not reside in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility (SNF), intermediate care facility (ICF) or special care facility.

PPECC services require prior authorization and are intended as an alternative to PDN. Members who receive PDN or quality for PDN also qualify for PPECC services. However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, personal care services (PCS), Home Health Skilled Nursing (HHSN), Home Health Aide (HHA), and therapies (physical therapy, occupational therapy, speech therapy), as well as respiratory therapy and Early Childhood Intervention services rendered in the member's residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but PPECC services must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

  • The development, implementation and monitoring of a comprehensive plan of care that:
    • is provided to a medically dependent or technologically dependent member;
    • is developed in conjunction with the member’s caregiver(s), ordering physician and interdisciplinary team;
    • specifies the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, and developmental needs of the member and the training needs of the member’s caregiver(s);
    • specifies if transportation to and from the PPECC is needed; and
    • is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
  • Direct skilled nursing care and caregiver training and education intended to:
    • optimize the member’s health status and outcomes; and
    • promote and support family-centered, community-based care as a component of an array of service options by:
      • preventing prolonged or frequent hospitalizations or institutionalization;
      • providing cost-effective, quality care in the most appropriate environment; and
      • providing training and education of caregivers;
  • Nutritional counseling and dietary services as specified in a member’s plan of care;
  • Assistance with activities of daily living while the member is in the PPECC;
  • Psychosocial and functional development services; and
  • Transportation services to and from a PPECC.
    • Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC.
    • When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle.
    • The member must be able to utilize transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance.
    • Transportation is billed separately by the PPECC when utilized by a member.
    • A non-emergency ambulance may not be utilized for transport to and from a PPECC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

  • baby food or formula;
  • services to members that are related to the PPECC owner by blood, marriage or adoption; and
  • services covered separately by Texas Medicaid, such as;
    • therapies;
    • durable medical equipment; or
    • individualized comprehensive case management beyond that required for service coordination.

Additional information about PPECC services can be found in the STAR Kids Managed Care Contract Section 8.1.24.15, the Uniform Managed Care Manual Chapter 16.1, and the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Chapter 2.14, Prescribed Pediatric Extended Care Centers.
 
Medicaid managed care organizations also must comply with Title 1 Texas Administrative Code, Part 15, Chapter 363, Subchapter B, Prescribed Pediatric Extended Care Centers.

 

 

4410 Assessment for Prescribed Pediatric Extended Care

Revision 20-2; Effective September 1, 2020

 

The Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

  • A current authorization for private duty nursing (PDN);
  • A skilled nursing visit or PDN is provided in a school or day program;
  • Member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing home stay in the past year;
  • Member requires enteral or parenteral feeding;
  • Member received any of the following treatments in the last 30 days:
    • Chemotherapy;
    • Dialysis;
    • Intravenous (IV) medication;
    • Oxygen therapy;
    • Radiation;
    • Suctioning;
    • Tracheotomy care;
    • Transfusion;
    • Ventilator;
    • Wound care;
    • Nebulizer;
    • Urinary catheter care –insertion or maintenance;
    • Comatose or persistent vegetative state – manage care'
    • Continuous positive airway pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP);
    • Chest percussive therapy;
    • Active medication adjustment;
    • Intermittent positive pressure breathing (IPPB); and/or
    • Seizure management; and
  • The member is being assessed for Community First Choice (CFC) services or the Medically Dependent Children Program (MDCP).

If triggered, the service coordinator completes the NCAM to determine the member's nursing needs. Based on the assessment, the service coordinator develops a recommended service plan for the services of a PPECC. The service coordinator works with the member or their authorized representative to locate an appropriate provider and sends an authorization to the selected provider.

Members who have received an NCAM assessment and been approved for PDN services do not require a new assessment if they choose a PPECC unless there is a change in condition and additional nursing hours are needed. MCOs who have PPECC providers available in the service area are expected to provide information to members who qualify for ongoing nursing services about their options of PDN, PPECC or a combination of both.

A member has a choice of PDN, PPECC or both, as long as the services are not provided at the same time. Example: Member has PDN from 7 a.m. to 8 a.m., PPECC from 9 a.m. to 2 p.m. and PDN in the evening.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.

 

 

4411 Authorization Requirements

Revision 20-2; Effective September 1, 2020

 

Initial, reauthorization and revision requests for Prescribed Pediatric Extended Care Center (PPECC) services must include the following documentation:

  • physician order for services (a physician signature on the PPECC plan of care (POC) serves as a physician order for authorization purposes);
  • a POC developed by the PPECC;
  • all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual or MCO forms if they contain comparable content; and
  • signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include:
    • an acknowledgement by the participant or the participant's responsible adult that they have been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services; and
    • consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care.

Forms available online for PPECC include:

  • Comprehensive Care Plan (CCP) Prior Authorization Request (requires ordering physician signature).
  • PPECC POC (requires ordering physician, PPECC registered nurse (RN) and member/responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the Texas Medicaid Provider Procedures Manual.
  • Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECC (requires ordering physician, PPECC RN and member/responsible adult signature). This form contains required individual and physician acknowledgements and consent.

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service forms and are subject to approval by HHSC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

 

4412 Reassessment and Reauthorization

Revision 20-2; Effective September 1, 2020

 

The need for, and the amount and duration of services from, a Prescribed Pediatric Extended Care Center (PPECC) must be reassessed by the PPECC provider:  

  • 90 days following initial authorization; and
  • every 180 days thereafter; or
  • when requested due to a change in the member's health; or
  • when the authorized services are not commensurate with the Member’s medical needs.

A physician order must be renewed with any reassessment.

 

 

4420 Providers of Prescribed Pediatric Extended Care

Revision 20-2; Effective September 1, 2020

 

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 56 Texas Administrative Code. Chapter 550 (relating to Licensing Standards for Prescribed Pediatric Extended Care Centers), and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24-hour period. Services may not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual and PPECC medical policy. These components include:

  • Member's name, date of birth and Medicaid number;
  • PPECC's name, Texas Provider Identifier (TPI), National Provider Identifier (NPI) and hours of operation, as well as address, telephone and fax numbers;
  • Ordering physician's name, telephone number, TPI and NPI;
  • Date the PPECC nursing assessment was completed and name, title and credentials of the registered nurse (RN) who completed the POC with their dated signature;
  • Name, title and credentials of the team member who completed the POC with their dated signature;
  • Date the member was last seen by the ordering physician;
  • Requested start of care date for PPECC services;
  • All pertinent diagnoses and known allergies;
  • Nursing services to be provided, including amount, duration and frequency;
  • Member's prognosis;
  • Member's mental status;
  • Rehabilitation potential;
  • Equipment and/or supplies required;
  • Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented;
  • Other prescribed services, including amount, duration and frequency;
  • Nutritional requirements, including type, method of administration and frequency;
  • Medications, including the dose, route, frequency and any medication-related allergies if known;
  • Treatments, including amount and frequency;
  • Wound care orders and measurements;
  • Safety measures to protect against injury;
  • Functional developmental services and psychosocial services, including amount, duration and frequency;
  • Name, telephone number and signature of the responsible adult;
  • Member’s emergency contact name and telephone number;
  • Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm or electrical malfunctions), and for emergencies that occur while the member is in the care of the PPECC;
  • List of services the member receives in the home and school settings. [e.g., Early Childhood Intervention (ECI), therapies, School Related Health Services (SHARS), personal care services (PCS), private duty nursing (PDN), therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL) and Community Living Assistance and Support Services (CLASS)].
    • Note: Services provided under these programs will not prevent a member from obtaining medically necessary services;
  • Member-specific measurable goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider;
  • Responsible adult training needs;
  • Prior and current functional or medical limitations;
  • Permitted activities;
  • Member's scheduled days and hours of attendance;
  • Confirmation of a discharge plan, including instructions for timely discharge or referral;
  • Method of transportation;
  • PDN provider name, TPI, NPI, telephone, address and fax number, if known;
  • Ordering physician signature and date of signature;
  • Transportation services needed by a member to access PPECC service (a non-emergency ambulance may not be used for transport to and from a PPECC); and
  • Services outlined in the Texas Administrative Code, Title 1, Part 15, Chapter 363 (Texas Health Steps Comprehensive Care Program), Subchapter B (Prescribed Pediatric Extended Care Center Services), §363.209 (Benefits and Limitations).

The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

  • Speech, physical, and occupational therapies (including therapies rendered by a home health agency);
  • Certified respiratory care services;
  • Early intervention services provided through the ECI program, which are subject to ECI policies.

In accordance with 2.14.1 of the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, therapy services (occupational, speech, physical and respiratory) rendered in a PPECC may be provided by:

  • therapists employed by or contracted with the PPECC; or
  • therapists contracted with the MCO but not employed by, or contracted with, the PPECC.

Therapy providers must be Medicaid enrolled and separately contracted and credentialed with the MCO, even if they are employed by, or contracted with, the PPECC. Therapy services must be authorized and billed separately from PPECC services, and the MCO's claims systems must accommodate PPECCs as a place of service for therapy services.

 

 

 

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

 

See Section 4310, Private Duty Nursing and Prescribed Pediatric Extended Care Services, for details on coordination of services between PDN and PPECC. Both PDN and PPECC are ongoing skilled nursing services and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC or a combination of both services.

 

 

4500 Day Activity and Health Services

Revision 17-1; Effective June 1, 2017

 

Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations may not require DAHS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for DAHS.

 

 

4510 Assessment for Day Activity and Health Services

Revision 19-1; Effective June 3, 2019

 

The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order.

A Day Activity and Health Services (DAHS) facility nurse must complete a health assessment for each STAR Kids member at the facility. The assessment may be conducted by a registered nurse (RN) or licensed vocational nurse (LVN), based upon the member's condition at the time of initial assessment. The DAHS facility nurse completes a health assessment at either the facility or the member's home. Health assessments must be conducted, at minimum, when:

  • members need initial assessment for prior authorization by a STAR Kids managed care organization;
  • members transfer to a new facility (conducted by the new facility);
  • at reauthorization; and
  • the DAHS nurse determines a member needs to be reassessed.

The member or his legally authorized representative must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member's functioning.

 

 

4511 Reassessment for Day Activity and Health Services

Revision 17-1; Effective June 1, 2017

 

Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment may be no older than 90 days from the date at which an authorization is requested.

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 Day Activity and Health Services facility; and
  • a member's condition changes. If the change in condition necessitates, the facility nurse coordinates with the member's service coordinator or physician for a physician assessment.

 

 

4520 Day Activity and Health Services Providers

Revision 19-1; Effective June 3, 2019

 

To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission and comply with Texas Administrative Code, Title 40, Part 1, Chapter 98, Adult Day Care and Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

  • Nursing services, which include a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of personal care services (PCS).
  • Physical rehabilitative services, which include restorative nursing and group/individual exercises with range of motion exercises.
  • Nutrition services, which include:
    • one hot noon meal a day;
    • a mid-morning and mid-afternoon snack;
    • preparation of foods required for special diets; and
    • dietary counseling and nutrition education for the individual and his family.
  • Transportation, including to and from the facility, as well as to and from the facility on an activity outing, and to and from a facility approved to provide therapies if the member requires specialized 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 individuals;
    • 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 to and from their homes.
  • 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 activities:
      • Exercise;
      • Games;
      • Educational or reality orientation; and/or
      • Crafts.
    • A provider must offer at least one of the following activities, at cost to the provider, monthly:
      • Trips or special events; or
      • Cultural enrichment.

 

 

4600 Medically Dependent Children Program Services

Revision 19-1; Effective June 3, 2019

 

The Medically Dependent Children Program (MDCP) provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, supported employment, and employment assistance to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility residents under 21 years of age.

Only members who are assessed as meeting medical necessity (MN) and who have a slot in the MDCP waiver are eligible for MDCP services. Federal guidelines require that members must need and use one or more waiver services to qualify and maintain eligibility for MDCP. The minimum utilization of MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they utilize Community First Choice (CFC), as described in Section 1530, Unmet Need for at Least One Waiver Service.

The managed care organization (MCO) service coordinator must inform all members receiving MDCP services of the requirements outlined in Section 1530 and the following:

  • If the member’s eligibility is Medical Assistance Only (MAO) and:
    • CFC has been authorized, at a minimum, one MDCP service must be utilized at least once a month to qualify and maintain enrollment in MDCP.
    • CFC has not been authorized, at a minimum, one MDCP service must be utilized at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.
  • If the member’s eligibility is not MAO and CFC has been authorized, at a minimum, one MDCP service must be utilized at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.

If a member is offered enrollment in MDCP or at an MDCP member's reassessment, during the STAR Kids assessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the service coordinator may discuss the member's needs as they relate to the available MDCP services. The service coordinator may develop a recommended individual service plan (ISP) if the member's Resource Utilization Group (RUG) is not known, as the RUG determines the member's budget.

Example: The service coordinator could ask the member and/or his caregiver if they would like respite or have a desire for employment services. The service coordinator could ask if the member requires adaptive aids, minor home modifications, or could benefit from flexible family support services. The service coordinator could inquire which services the member/caregiver would like more of, should the member's budget be unknown during the assessment. Based on the discussion, the service coordinator could develop a recommended ISP for that member and work with the member/caregiver in person or telephonically to develop a final service plan once the member's budget is known.

 

 

4700 Medically Dependent Children Program Respite and Flexible Family Support Services

Revision 17-1; Effective June 1, 2017

 

 

 

 

4710 Medically Dependent Children Program Respite

Revision 17-1; Effective June 1, 2017

 

Respite is a service that provides temporary relief from caregiving to the applicant/member or his primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the applicant's/member's parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for respite services.

In-home respite may be delivered by a Home and Community Support Services Agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. Respite may be delivered by attendants or nurses employed through the CDS option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member's relative. Out-of-Home Respite may be provided in a facility setting, such as a nursing facility or hospital, or in a camp setting.

Respite is intended to provide relief to the primary caregiver. It may only be provided when a member's primary caregiver would normally provide the member's care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or Private Duty Nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite is a service to provide relief to the primary caregiver, if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member's home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks he would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that scenario, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.

STAR Kids MCOs may determine the number of units of respite to authorize for an MDCP member, based on the member and/or legally authorized representative's preferences and the member's approved cost limit. MCOs must develop internal processes related to respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP. The MCO must document banked hours using Form 2605, Respite Tracking Tool.

 

 

4711 In-Home Respite

Revision 19-1; Effective June 3, 2019

 

In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, the respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member or his legally authorized representative (LAR) under the Consumer Directed Services (CDS) option.

A member's in-home respite is limited by the amount of the member's cost limit. If the member chooses the CDS option, the member is limited by his available budget. Managed care organizations (MCOs) may have additional policies and procedures regarding reserving capacity in a member's budget. The provision of in-home respite is documented on the individual service plan (ISP).

 

 

4711.1 Attendant with Delegated Tasks

Revision 19-1; Effective June 3, 2019

 

A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his supervision, per BON rules. A member with a skilled task need may to use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled task need for the delivery of respite, he does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the Home and Community Support Services Agency (HCSSA) provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or his or her LAR is directing the member's services, he or she must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

 

4712 Out-of-Home Respite

Revision 19-1; Effective June 3, 2019

 

Respite may be provided out of the home if indicated in a physician's order or if the member and/or his legally authorized representative (LAR) prefer. Out-of-home respite providers are:

  • special care facilities licensed by the Texas Department of State Health Services (DSHS);
  • day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
  • hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
  • nursing facilities licensed by the Texas Health and Human Services Commission (HHSC);
  • camps licensed by DSHS and accredited by the American Camping Association; and
  • foster families approved by a DFPS child placing agency.

Facility-based respite is limited to 29 days per the individual service plan period. The 29-day limit applies to the total number of days a member receives respite in a hospital or nursing facility.

 

 

4720 Respite Limits

Revision 19-1; Effective June 3, 2019

 

Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.

Title 42 of the Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member's admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.

The member may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:

  • primary caregiver;
  • member's spouse; or
  • member's parent, representative, guardian or managing conservator, if the individual is under age 18.

 

 

4730 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

 

 

 

4740 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

 

 

 

4750 Flexible Family Support Services

Revision 19-1; Effective June 3, 2019

 

Flexible family support services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:

  • child care;
  • independent living; and
  • post-secondary education.

FFSS include personal care supports for basic activities of daily living and instrumental activities of daily living, skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. Flexible family support services may be delivered by the Home and Community Support Services Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services option. FFSS are documented on the individual service plan. STAR Kids managed care organizations may not require FFSS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for FFSS.

 

 

4751 Flexible Family Support Services in Child Care

Revision 19-1; Effective June 3, 2019

 

The member's parent or guardian is responsible for basic child care either in or out of the member's home. Flexible family support services (FFSS) support the member's participation in child care when the service provided by the child care does not support the member's disability-related needs. If the member's child care is not able to meet the member's activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task needs, the service coordinator may authorize FFSS.

To determine the need for FFSS for participation in child care, the service coordinator must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the member's home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.

The caregiver's cost for child care does not impact the member's need for FFSS. The service coordinator must determine the amount of hours needed to support the member's needs within the Medically Dependent Children Program (MDCP) cost limit. The service coordinator should ask the caregiver about the member's personal and skilled task needs and the time needed to address those needs. The service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member's health and welfare.

FFSS does not replace personal care services (PCS) provided through Texas Health Steps (THS) or Community First Choice (CFC). FFSS are provided when a member regularly participates in child care in the home or out of the home, or participates in a community program or educational service. FFSS are authorized because of a change in the child's condition or when because of the child's condition, the child’s needs cannot be met. In these instances, additional care is required.

 

 

4752 Flexible Family Support Services for Independent Living

Revision 19-1; Effective June 3, 2019

 

A member may indicate a desire for increased independence as he or she matures. If the member needs assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with his or her goal for independent living.

Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program (MDCP) service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills they will need to live independently as adults.

To determine the need for FFSS for independent living, the service coordinator must discuss the member's and primary caregiver's plan for the member's independent living. When identifying the member's need for this service, the service coordinator should address age appropriateness for the tasks required to meet these needs. The service coordinator must determine the amount of FFSS needed to support the member's needs. The service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member's age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.

 

 

4753 Flexible Family Support Services in Post-Secondary Education

Revision 17-1; Effective June 1, 2017

 

A member can access flexible family support services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the service coordinator may authorize FFSS so the member may participate in post-secondary education.

A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member's personal, skilled and delegated skilled task needs.

To determine the need for FFSS in post-secondary education, the service coordinator must identify the member's need for assistance and the amount of FFSS needed to support the member's needs. The service coordinator should identify the member's personal and skilled task needs and the amount of time needed to address those needs. The service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member's health and welfare.

 

 

4754 Flexible Family Support Services Requiring Delegated Tasks

Revision 17-1; Effective June 1, 2017

 

A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only a Home and Community Support Services Agency (HCSSA) nurse may delegate to an attendant under his supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled task need for the delivery of flexible family support services (FFSS), he does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or his legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through CDS, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or his LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

 

 

4760 Flexible Family Support Services Limits

Revision 19-1; Effective June 3, 2019

 

Flexible family support services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the service coordinator may not authorize FFSS during the same time period the individual receives personal care services (PCS) or Community First Choice (CFC).

42 Code of Federal Regulations §446.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID).

The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.

 

 

4800 Adaptive Aids, Minor Home Modifications, and Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

 

 

 

4810 Adaptive Aids

Revision 19-1; Effective June 3, 2019

 

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to:

  • perform activities of daily living (ADLs); or
  • control the environment in which they live.

A member must exhaust any applicable Medicare, Medicaid or other third-party resources for durable medical equipment and adaptive aids before adaptive aids available under the Medically Dependent Children Program (MDCP) are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.

 

 

4811 Service Limits on Adaptive Aids

Revision 19-1; Effective June 3, 2019

 

The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. After any applicable state plan benefits (e.g., durable medical equipment) are exhausted, adaptive aids covered in the Medically Dependent Children Program (MDCP) include:

  • van lifts;
  • vehicle modifications;
  • jump seats;
  • tumble form chairs;
  • feeder seats;
  • medically appropriate strollers;
  • barrier-free lifts;
  • stair lifts;
  • environmental control units;
  • alarm systems;
  • support rails;
  • electrical work related to use of authorized adaptive aids;
  • installation of authorized adaptive aids; and
  • repairs to adaptive aids.

The managed care organization (MCO) may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member's annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.

 

 

4820 Minor Home Modifications

Revision 19-1; Effective June 3, 2019

 

A minor home modification is a physical modification to a member's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in his or her home. If a home modification is requested and the member or his legally authorized representative (LAR) does not own the home in which the modification will take place, the member, LAR, or the service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids managed care organizations (MCOs) may not require minor home modification providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for minor home modifications services.

 

 

4821 Service Limits on Minor Home Modifications

Revision 17-1; Effective June 1, 2017

 

The minor home modification lifetime limit is $7,500. The service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. A minor home modification must not create a new structure or add square footage to the home.

The managed care organization (MCO) may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member's lifetime limit for minor home modifications.

Minor home modifications are limited to:

  • purchase and installation of permanent and portable ramps not covered by other sources;
  • widening of doorways;
  • modification of bathroom facilities; and
  • modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

Minor home modifications must:

  • adhere to Americans with Disabilities Act (ADA) requirements;
  • meet Texas Accessibility Standards;
  • meet all applicable state and/or local building codes; and
  • have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider's warranty, the service coordinator may authorize up to $300 for the member or his legally authorized representative to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.

 

 

4822 Time Frames for Minor Home Modifications

Revision 21-1; Effective April 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 MHM service is added 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 proposed 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.

 

 

4830 Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

The service coordinator must advise applicants or members who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the applicant or member needs assistance in setting up a household when relocating into the community from the NF. STAR Kids managed care organizations (MCOs) may not require TAS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for TAS. The applicant or member may access TAS if they:

  • plan to rent an apartment;
  • plan to rent a house;
  • have a home, but the utilities have been off while in the NF;
  • have a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
  • need belongings moved from the NF to the new residence.

TAS may be available to pay for non-recurring set-up expenses for applicants/members transitioning from NFs into MDCP and to individuals temporarily suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the applicant's or member's transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

  • security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
  • essential furnishings for the apartment or house;
  • moving expenses required to move into the house or apartment; and
  • site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

The applicant or member selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the applicant, member, or legally authorized representative to attest that the items requested for TAS are the basic, essential needs required to move into the community, and they agree the TAS agency selected is authorized to make the purchases for them. The service coordinator must explain to the applicant or member that the service will not be authorized until the applicant or member is determined eligible for MDCP waiver services, and notified in writing that he or she is eligible. The service coordinator must contact the applicant/member or applicant's/member's representative before certification to verify the applicant or member has made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member received must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.

 

 

4831 Deposits

Revision 17-1; Effective June 1, 2017

 

The service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's or member's name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months' rent. The service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the applicant's or member's service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the applicant's or member's name or to pay for arrears on previous utilities if the account is in the applicant's or member's name and he or she will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The managed care organization (MCO) may have internal policies regarding the type of telephone that may be authorized.

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 requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the applicant's or member's transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the applicant's or member's place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or member identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the applicant or member not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.

 

 

4832 Moving Expenses

Revision 17-1; Effective June 1, 2017

 

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the applicant's or member's belongings from the nursing facility to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or member from the nursing facility to his or her residence in the community.

 

 

4833 Site Preparation

Revision 17-1; Effective June 1, 2017

 

Transition Assistance Services (TAS) can be used to pay for preparing the applicant's or member's place of residence for occupancy if the current condition of the residence prevents the applicant's or member's transition from the nursing facility. Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and is in need of some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the applicant or individual is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the applicant's or member's 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.

 

 

4834 Limits on Transition Assistance Services

Revision 17-1; Effective June 1, 2017

 

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per applicant or member. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. The service coordinator must be as specific as possible when describing the items purchased. A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to nursing facility placement may receive a one-time TAS authorization if the service coordinator determines that no other resources are available to pay for the basic services or items needed by the applicant or member. TAS may not be used for:

  • monthly rent or mortgage expenses;
  • current or future use of utilities;
  • service upgrades;
  • food items; or
  • any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to applicants or members who are discharged from a nursing facility and require TAS to set up a household.

 

 

4835 Transition Assistance Services Agency Responsibilities

Revision 19-1; Effective June 3, 2019

 

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 authorization carefully and contact the MCO if there are any questions regarding the authorization. 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 or his legally authorized representative (LAR), if necessary, to discuss the item in question. The MCO provides a revised TAS authorization 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/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member or member's authorized representative, 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 the member's representative by the completion date to confirm that all authorized TAS services were delivered.

 

 

4836 Three-Day Monitor Requirement

Revision 17-1; Effective June 1, 2017

 

The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. 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.

 

 

4837 Failure to Leave the Facility

Revision 17-1; Effective June 1, 2017

 

While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the facility, there may be situations in which the member changes his mind or has a change in health making it impossible for him 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 individual 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. Failure to leave a facility does not count against a member's lifetime TAS limit.

  • 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 individual cannot be recouped, the TAS agency is entitled to the 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 the individual to 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 cost 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, the member keeps the item(s) purchased through TAS.

 

 

4900 Supported Employment and Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Senate Bill 45, 83rd Legislature, Regular Session, 2013, required all Medicaid waivers offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program are EA and SE. STAR Kids managed care organizations may not require SE or EA providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for SE or EA services.

 

 

4910 Employment Assistance

Revision 19-2; Effective December 2, 2019

 

Employment assistance (EA) is provided to a member receiving Medically Dependent Children Program (MDCP) services to help the individual 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.

For any MDCP member, the service coordinator must ensure and document that employment services are not available to the member from the member's school district or other available community resource before authorizing EA services.

The service coordinator refers the member to the Texas Workforce Commission (TWC) within 30 days of meeting with a member and identifying an interest in obtaining employment. The service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at http://www.twc.state.tx.us/directory-workforce-solutions-offices-services-0#workforceServices.

A member who has been referred for TWC or contacted TWC himself is eligible to receive EA through MDCP until TWC has developed the Individualized Plan of Employment (IPE) and the member has signed it, or until the member is denied services through TWC. If a member refuses to contact TWC, he or she may not receive waiver-funded EA. If a member is denied assistance through TWC, EA through MDCP may be authorized.

If the member has exhausted TWC services or been determined ineligible for TWC services, the service coordinator authorizes a minimum of 10 hours for employment on the member's individual service plan (ISP). EA can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member's MDCP budget.

 

 

4911 Coordination with Texas Workforce Commission for Employment Assistance

Revision 17-1; Effective June 1, 2017

 

Upon request and with proper authorization for disclosure, the service coordinator will assist the member to provide the Texas Workforce Commission (TWC) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

  • Photo identification;
  • An original Social Security card;
  • Member's home address and mailing address;
  • Names and addresses of any doctors the member has seen recently;
  • Names and addresses of any schools the member has attended;
  • Information about the member's medical insurance;
  • A list of places the member has worked, including type of job, dates, the reason for leaving and salary;
  • Proof of income for the member and his or her spouse, or parents (if the parents claim the member as a dependent on their income tax);
  • Proof of expenses related to monthly mortgage/rental payments, debts imposed by court order, personal medical costs and other disability-related expenses;
  • Names, addresses and telephone numbers of two people who will always know how to contact the member;
  • Any reports of recent medical exams, school records or other information that may help the VRC understand the member's disability;
  • Member's most recent service plan;
  • Any current vocational assessments or person-directed plans that focus on employment opportunities;
  • Any other available records pertaining to the member's disabilities, including but not limited to medical, psychological and psychiatric reports;
  • A copy of the member's court-ordered guardianship documents, if any guardian has been appointed; and
  • Contact information for the member's service coordinator.

If the VRC determines that TWC is not the appropriate resource to meet the member's needs and does not take an application for services, documentation of this decision in the member's record serves as sufficient evidence that TWC is not available and the member is eligible to receive waiver-funded employment assistance.

TWC will:

  • Notify a member in writing if the member is determined to be eligible, ineligible or if TWC is unavailable;
  • Notify a member in writing when TWC is completed;
  • Develop with the eligible member an Individualized Plan for Employment (IPE) within 90 days of determination of eligibility for services;
  • After the IPE is completed, begin coordinating the provision of services as identified on the IPE; and
  • Upon request and with proper authorization for disclosure, provide copies of any of the member's records to the service coordinator, including the following documents:
    • A completed copy of the member's application statement;
    • A member's completed IPE;
    • Written documentation specifying a member's eligibility status; and
    • The notification letter indicating TWC is completed.

If TWC has not notified the member of an eligibility decision within 60 days of the initial TWC appointment, the member's service coordinator will attempt to contact the assigned TWC VRC to determine the status of the application and document the contact in the narrative notes.

The member's service coordinator will ensure that communication is maintained with the assigned TWC VRC regarding waiver-funded services provided between the Vocational Rehabilitation (VR) referral and the "start date" of TWC, as defined in the individual's TWC VR IPE.

At the request of a member determined eligible for TWC, the service coordinator, if possible, will assist the member and:

  • participate in TWC planning meetings related to the member's employment, or ensure other individuals important to the member attend, as appropriate;
  • take an active role in providing input to the TWC IPE, or ensure other individuals important to the member provide input, as appropriate; and
  • review the long term services and supports listed on the TWC IPE and if any of those services and supports are available through the waiver, incorporate them in a revision to the member's service plan prior to the end of TWC services.

The member's provider must begin providing or subcontracting for those services and supports approved in the member's service plan without a gap between the provision of TWC and waiver services.

 

 

4912 Employment Assistance Providers

Revision 17-1; Effective June 1, 2017

 

Employment assistance providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or his legally authorized representative (LAR) under the Consumer Directed Services (CDS) option. At a minimum, the employment assistance provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the individual, and 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 paid or unpaid experience providing services to people with disabilities.

Option 2:

  • An associate's degree in rehabilitation, business, marketing, or a related human services field; and
  • One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

  • A high school diploma or Certificate of High School Equivalency (GED credentials); and
  • Two years of paid or unpaid experience providing services to people with disabilities.

Under the CDS option, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

 

 

4920 Supported Employment

Revision 17-1; Effective June 1, 2017

 

Supported employment (SE) services provide assistance to help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.

SE services include:

  • assistance provided to a member to sustain competitive employment and 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;
  • employment adaptations, supervision and training related to a member's assessed need; and
  • ensuring members earn at least minimum wage, if not self-employed.

Competitive employment is work:

  • in the competitive labor market in which anyone may compete for employment that is performed on a full-time or part-time basis in an integrated setting; and
  • for which a member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

An integrated setting is a setting typically found in the community in which members interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting in which:

  • groups of people with disabilities work in an area that is not part of the general workplace where people without disabilities work; or
  • a mobile crew of people with disabilities work in the community.

An MDCP member may seek SE to provide assistance to the member in maintaining self-employment. Self-employment is work in which the member:

  • solely owns, manages and operates a business;
  • is not an employee of another person, entity or business; and
  • actively markets a service or product to potential customers.

SE may only be authorized through the MDCP waiver if 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.) or the Texas Workforce Commission.

 

 

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 19-1; Effective June 3, 2019

 

The service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third party resources before using Medically Dependent Children Program (MDCP) employment services, including school districts.

Activities include:

  • devoting time during a member's initial service planning meeting to discuss employment with the member and family and the process to obtain employment services and supports;
  • making a referral to TWC, assisting with completing the application form, and documenting the referral and outcome of the referral in the member's case record;
  • continuing to explore the possibility of employment at subsequent service planning meetings for a member who is not employed in the community;
  • affirming or explaining how a member can work and still maintain current medical benefits (e.g., through the Medicaid Buy-In program), and in most cases will have an increase in income;
  • explaining rights to appeal if services are denied, reduced or terminated; and
  • monitoring whether the member and family are satisfied with the employment supports.

 

 

4922 Supported Employment Providers

Revision 19-1; Effective June 3, 2019

 

Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or his legally authorized representative under the Consumer Directed Services (CDS) option. As a minimum, the SE provider must be at least 18 years of age, maintain a current driver license and insurance if transporting individual, and 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 paid or unpaid experience providing services to people with disabilities.

Option 2:

  • An associate's degree in rehabilitation, business, marketing, or a related human services field; and
  • One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

  • A high school diploma or Certificate of High School Equivalency (GED credentials), and
  • Two years of paid or unpaid experience providing services to people with disabilities.

Under CDS, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

Section 5000, Service Delivery Options

Section 5000, Service Delivery Options rarefyev Wed, 03/22/2017 - 08:57
Body

Revision 20-2; Effective September 1, 2020

 

5010 Selection of a Service Delivery Option

Revision 20-1; Effective March 16, 2020

 

Managed care organization (MCO) service coordinators must present all service delivery options to the applicant or member and/or the legally authorized representative (LAR) at the initial assessment and each annual reassessment. The MCO service coordinator may use Form 1581, Consumer Directed Services Overview, and Form 1582, Consumer Directed Services Responsibilities, or a document created by the MCO and approved by the Texas Health and Human Services Commission (HHSC), to assist the member or applicant in making the service delivery decision.

 

5020 Member Decision

Revision 20-1; Effective March 16, 2020

 

The managed care organizations (MCOs) must obtain a signature on Form 1584, Consumer Participation Choice, indicating the member's choice of option. If, at any time during the year, a current member requests information on service delivery options, the MCO must present the information to the member.

The MCO service coordinator must keep Form 1584 in the member's case record. The MCO service coordinator must ensure the member or legally authorized representative (LAR) understands they may request a service delivery option change at any time by contacting the MCO service coordinator.

 

5100 Agency Option

Revision 20-1; Effective March 16, 2020

 

 

 

5110 Description

Revision 20-1; Effective March 16, 2020

 

In the agency option, the managed care organization-contracted provider is responsible for managing the day-to-day activities of the direct service provider and all business details. Some individuals select the agency option because of the simplicity and convenience of receiving services. For example, in the agency option, it is the provider agency, not the member, that is responsible for:

  • locating qualified attendant(s) to provide services;
  • any negligent acts or omissions by the attendant(s), and liability for those acts;
  • handling all conflicts with the attendant(s);
  • any business details related to service delivery; and
  • training the attendant(s).

 

5200 Consumer Directed Services

Revision 20-1; Effective March 16, 2020

 

 

 

5210 Overview

Revision 20-1; Effective March 16, 2020

 

Consumer Directed Services (CDS) allows a member or legally authorized representative (LAR) to hire and manage the people who provide services within the member’s current home and community-based 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. The rules for the CDS option are found in Texas Administrative Code, Title 40, Chapter 41, and are applicable to the STAR Kids and Medically Dependent Children (MDCP) waiver programs.

CDS is a service delivery option in which a member or LAR becomes the CDS employer of record for certain services. The CDS employer recruits, hires, trains, and supervises service providers and directs the delivery of services available through the CDS option, described in Section 5212, STAR Kids Services Available Under the Consumer Directed Services Option. CDS employers are required to use a financial management services agency (FMSA), contracted with the managed care organization to provide financial management services (FMS). FMSAs conduct payroll and pay employer federal and state taxes on behalf of CDS employers, and provide orientation and ongoing support for members who choose the CDS option. FMSA roles and responsibilities are explained in more detail in Section 5233, FMSA Responsibilities.

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 employer responsibilities required for participation in the CDS option;
  • the member or LAR selects an FMSA to provide 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 DR to assist in performing employer responsibilities.

 

5211 Consumer Directed Services 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 interdisciplinary 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 service delivered through the CDS option.

CDS employer — The member or LAR who chooses to participate in the CDS option and is responsible for hiring, training, managing and retaining 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 employer. The DR is not the CDS employer. The DR must be a volunteer and cannot be a paid service provider. The CDS employer is responsible for actions taken by the DR.

Employee — A person employed by the member or 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 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 service agency (FMSA) to the member or LAR, as described in Section 5233, 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 member with regard to Consumer Directed Services, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult.

Service back-up 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 — 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 Consultation — A service that provides skills training and assistance for performing employer-related responsibilities.

 

5212 Services Available in the CDS Option

Revision 20-2; Effective September 1, 2020

 

STAR Kids services available in the Consumer Directed Services (CDS) option are:

  • Community First Choice (CFC) Personal Assistance Services;
  • CFC Habilitation; and
  • Personal Care Services.

The Medically Dependent Children Program (MDCP) waiver services and supports currently available in the CDS option are:

  • Respite Services;
  • Flexible Family Support Services;
  • Supported Employment; and
  • Employment Assistance.

Beginning September 1, 2020, MDCP waiver services and supports available in the CDS option are:

  • Respite Services;
  • Flexible Family Support Services;
  • Adaptive Aids;
  • Minor Home Modifications;
  • Supported Employment; and
  • Employment Assistance.

A member or their legally authorized representative (LAR) may choose to self-direct any, or all, of the services that are available through the CDS option. The CDS option is available to members living in their own homes or the homes of family members.

Choosing the CDS option does not impact a member's eligibility for services. A member or LAR can choose to have the above services delivered through the service delivery option of their choice.

Financial management services (FMS) are required in the CDS option. FMS provide assistance to members to manage funds associated with services elected for self-direction and is provided by a financial management service agency (FMSA) contracted with the member’s managed care organization (MCO). This includes initial orientation and ongoing training related to CDS employer responsibilities, as well as 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 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.

 

5220 Advantages and Risks of the Consumer Directed Services 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 choice, the managed care organization (MCO) service coordinator presents information about service delivery options to the member or LAR. Refer to Section 5221, Advantages of Consumer Directed Services (CDS) Service Delivery Option, below.

 

5221 Advantages of Consumer Directed Services (CDS) Service Delivery 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 delivery of services;
  • can appoint an eligible person as a designated representative to assist with or perform CDS employer responsibilities; and
  • may use budgeted funds to hire a support advisor, if they need assistance beyond what the FMSA provides.

 

5222 Potential Risks Associated with the Consumer Directed Services 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 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 service 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, service providers and the designated representative;
  • responsible for handling all conflicts with service providers. The CDS employer can request support consultation services be added to their service plan and budget to provide training and assistance with this CDS 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 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; and
  • responsible for meeting all state and federal requirements as an employer and can be held liable for failure to meet those requirements.

 

5230 Member and Financial Management Service Agency Responsibilities

Revision 20-1; Effective March 16, 2020

 

 

 

5231 Member Responsibilities

Revision 20-1; Effective March 16, 2020

 

The member or legally authorized representative (LAR) assumes responsibility as the CDS 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 service 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 employee and 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 welfare; 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 managed care organization service coordinator.

 

5232 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. A CDS employer may appoint a willing adult as a DR to assist or to perform employer responsibilities. The 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 CDS 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 financial management services agency (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 FMSA 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 CDS employer responsibilities, the person-centered service planning team may recommend that the employer designate a DR to assist with or to perform CDS employer responsibilities.

 

5233 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 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;
  • 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 the reimbursement and monitor 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, Texas Workforce Commission 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.

 

5240 Member Choice in the Consumer Directed Services Option

Revision 20-1; Effective March 16, 2020

 

Information about the Consumer Directed Services (CDS) option is presented to the STAR Kids 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 delivered through the agency or service responsibility option.

 

5241 Presentation of the CDS Option

Revision 20-1; Effective March 16, 2020

 

At the time of a member’s enrollment in STAR Kids or the Medically Dependent Children Program (MDCP), 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 a 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 (CDS) 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 declining participation in the CDS option may at any time elect to participate in the CDS option while receiving services through STAR Kids or MDCP.

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 legally authorized representative (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 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 appoints a designated representative (DR), if needed, or records the choice not to participate in the CDS option;
  • assists the member or LAR in selecting and appointing the DR, or their choice not to participate;
  • 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 employer's DR must be able to complete the Consumer Self-Assessment for the member receiving services to participate in the CDS option.

If a CDS employer would like to use a DR, the financial management services agency (FMSA) assists the CDS employer in appointing a DR after the FMSA has been selected.

Refer to Section 5232, Designated Representative, for procedures related to a member appointing a DR.

 

5250 Declining the CDS Option

Revision 20-1; Effective March 16, 2020

If the member or legally authorized representative (LAR) declines or is not ready to select the Consumer Directed Services (CDS) option at any point after reviewing Form 1581, Consumer Directed Services (CDS) Option Overview, 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 option; and
  • signs and dates Form 1584.

The MCO service coordinator must ensure the member understands the CDS option is always available and that the individual may call the service coordinator to request a change to the CDS option at any time.

Form 1584 is signed by the member when a different service delivery option is chosen.

 

5300 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:

  • Form 1582, Consumer Directed Services Responsibilities;
  • Form 1583, Employee Qualification Requirements;
  • Form 1584, Consumer Participation Choice;
  • 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 Licensure for Certain Services Delivered through Consumer Directed Services, if required by the policies of the member's program; and
  • 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 the CDS option. The MCO service coordinator develops the member’s service plan according to policy and CDS option rules.

 

5310 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 a CDS 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 (HCSSAs) 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 Kids and Medically Dependent Children Program (MDCP) services that are not delivered under the CDS option.

The MCO service coordinator develops the individual service plan (ISP) according to STAR Kids and MDCP program policy and CDS option rules.

 

5311 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 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 Kids and Medically Dependent Children Program (MDCP) 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 Kids and MDCP program services, including Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool.

The member using the CDS option must have a back-up plan to assure the provision of certain or critical authorized CDS services 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 5323, Service Back-Up Plans.

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.

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 Kids program and MDCP services, as well as actions that could affect the member's participation in the CDS option.

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 who develops the plan of care in the CDS option.

 

5312 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 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 Kids program or Medically Dependent Children Program (MDCP), new applicants who choose the CDS option are referred to the FMSA they select to begin the initiation process.

Within five business days of receipt of the completed Form 1584, ongoing STAR Kids program or MDCP 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.

Members who participate in the CDS option and choose to transfer back to the agency option will not have the choice of returning to the CDS option for at least 90 days.

MCO service coordinators must carefully coordinate transition activities when transitioning applicants or members to and from the CDS option.

 

5313 Initiation and Orientation of the Member as CDS Employer

Revision 20-1; Effective March 16, 2020

Upon choosing to participate in the Consumer Directed Services (CDS) option, a CDS employer, legally authorized representative (LAR) and the designated representative (DR), if applicable, must:  

  • complete the initial CDS employer orientation provided by the financial management services agency (FMSA) in the member's residence 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 for Consumer Directed Services;
  • as required by the member's program, complete Form 1733, Employer and Employee Acknowledgement of 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. 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 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, LAR 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 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, LAR and DR, if applicable, printed information on how to report allegations of abuse, neglect and exploitation.

The FMSA must provide to the CDS employer, LAR 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 before initiation of the CDS option.

The CDS employer or DR, if applicable, 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.

5314 Employer and Employee Acknowledgment of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services

Revision 20-1; Effective March 16, 2020

If the Consumer Directed Services (CDS) employer will assume responsibility for training and supervising an unlicensed service provider to perform certain health related tasks, the financial management service agency (FMSA) assists the 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 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 the STAR Kids program or Medically Dependent Children Program (MDCP) before the CDS employer or DR hires the service provider.

5315 Authorizing CDS

Revision 20-1; Effective March 16, 2020

For members new to Consumer Directed Services (CDS), following orientation the member or legally authorized representative (LAR) and financial management services agency (FMSA) notify the managed care organization (MCO) service coordinator that CDS services are ready to begin. The service coordinator negotiates a start date for services and revises Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, and changes the appropriate CDS services authorizations to the FMSA. For ongoing members, the individual service plan 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.

 

5320 Ongoing CDS Requirements and Process

Revision 20-1; Effective March 16, 2020

 

The financial management services agency (FMSA) must send a quarterly expenditure report to the CDS employer and service coordinator and document and notify the managed care organization (MCO) of issues or concerns, including:

  • allegations of abuse, neglect, exploitation or fraud;
  • concerns about the member's health, safety or welfare;
  • 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 member's service plan for delivery of services to the member through the Consumer Directed Services (CDS) option and in accordance with the requirements of the STAR Kids program or Medically Dependent Children Program (MDCP).

The CDS employer is required to participate in the service planning meetings and provide requested documentation related to services and service delivery. The member or legally authorized representative (LAR) must provide documentation to support any requests for a revision to the individual service plan.

The FMSA may also participate in the member's service planning, if requested by the member, LAR or designated representative (DR), and if agreed to by the FMSA. The MCO and service planning team 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 5323, Service Back-Up Plans.

 

5321 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 Kids and Medically Dependent Children Program (MDCP) waiver program service to be delivered through the CDS option;
  • pay employees in accordance with minimum wage laws and any other applicable base wage requirements;
  • 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;
  • 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.

The FMSA must provide assistance, as requested or needed, by the member, LAR or DR to develop a budget. The FMSA reviews the member's budgeted payroll spending decisions, verifies the applicable budget workbooks are within the approved budget, and notifies the member in writing of budget approval or disapproval.

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 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 FMSA must assist the CDS employer or DR to resolve issues that prevent the approval of budget plans.

The MCO service coordinator evaluates ISP changes requested by the CDS employer and participates in the interdisciplinary team meetings to resolve issues when the CDS employer or DR does not follow the budget or comply with CDS option budget requirements.

 

5322 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 employer support services and start-up expenses through the services that are delivered by one or more employees in the CDS option. Employer support services include employment-related expenses, employer-related expenses and support consultation services. 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;
  • cardiopulmonary 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 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.

A CDS employer or DR may budget up to 10 percent of the amount available, after the FMSA portion is calculated, in those services delivered by one or more employees. A CDS employer or DR must not budget more than $600 annually or more than $50 per month if less than 12 months remain in the service plan for employer support services.

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.

 

5323 Service Back-Up Plans

Revision 20-1; Effective March 16, 2020

The managed care organization (MCO) service coordinator must discuss with the Consumer Directed Services (CDS) employer or designated representative (DR) the services delivered through CDS that are critical to the member's health and welfare. The MCO service coordinator 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 authorized service plan). 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 and service planning team, as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or service planning team must approve each service back-up plan and any revision before implementation by the member, LAR or DR. The MCO service coordinator approves the service back-up plan by signing, dating and returning a copy of the plan to the CDS employer or DR.

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 service planning team.

The FMSA must:

  • assist a CDS employer or DR as requested to revise budget to meet service back-up plan strategies approved by the member's service planning team;
  • 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.

 


5324 Corrective Action Plans

Revision 20-1; Effective March 16, 2020

The Consumer Directed Services (CDS) employer, meaning the member or legally authorized representative (LAR) or designated representative (DR), must provide a written corrective action plan (CAP) to the person requiring the plan within 10 days after receiving a CAP request. CAPs may be requested in writing by the financial management services agency (FMSA) or managed care organization (MCO) service coordinator.

A written CAP may be required from an employer or designated representative (DR) if the 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; or
  • does not meet other employer responsibilities.

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 employer responsibilities; and
  • MCO, if the CAP is related to the Medically Dependent Children Program waiver STAR Kids rules or requirements.

Form 1741, Corrective Action Plan, is used to document the CAP.

5330 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. Termination from the CDS option must last at least 90 days.

A member’s managed care organization (MCO) service coordinator convenes the member's service planning team concerning issues that may warrant immediate termination of the member's participation in the CDS option. On review of the information, the service planning team may recommend immediate termination of participation in the CDS option when:

  • the member's health or welfare 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 service planning team may recommend termination of participation in the CDS option in accordance with the member's program requirements:

  • eliminate jeopardy to the member's health or welfare;
  • successfully direct the delivery of program services through CDS;
  • meet employer responsibilities;
  • successfully implement corrective action plans; or
  • appoint a DR or access other available supports to assist the employer in meeting 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 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 service planning team 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 welfare for continued participation in the CDS option; and
    • make revisions to the member's service plan, if needed.

If the service planning team 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 service planning team 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.

 

5331 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 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 service planning team 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.

 

5400 Service Responsibility Option Description

Revision 20-1; Effective March 16, 2020

 

The Service Responsibility Option (SRO) empowers the member to manage most day-to-day activities. This includes supervision of the individual providing direct services.

The member decides how services are provided. The SRO leaves the business details to the member's managed care organization (MCO) and contracted provider. The rules for the SRO are found in Texas Administrative Code, Title 40, Chapter 43.

See STAR+PLUS Handbook, Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of all available service delivery option features.

 

5410 Service Responsibility Option 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 or LAR, provider and MCO receive and sign Form 1582-SRO indicating their agreement to accept the service responsibility option responsibilities.

 

5411 Managed Care Organization Responsibilities

Revision 20-1; Effective March 16, 2020

 

The intake, referral and assessment procedures for the member or legally authorized representative (LAR) 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 about all options for managing services; and
  • review Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, with the member 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;
  • explaining SRO rights, responsibilities and resources to the member or LAR;
  • presenting the MCO provider list and the support consultation provider to the member or LAR;
  • making a referral to the provider(s) selected by the member or LAR;
  • processing the member's request to change service delivery options;
  • redeveloping the service plan 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 a service planning team meeting in instances where the member has:
    • health and safety concerns;
    • difficulty selecting or keeping an attendant; or
    • other issues relating to services that cannot otherwise be resolved; and
  • monitoring services in accordance with Section 5422, Monitoring.

 

5412 Agency Responsibilities

Revision 20-1; Effective March 16, 2020

 

The agency contracted with the managed care organization (MCO) is the attendant's 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 staff:

  • discuss and negotiate potential back-up plans for those times when the attendant is absent from work;
  • send a maximum of three attendants, including any individuals recommended by the member, for the member to review;
  • explain to the selected attendants that the agency is the employer of record and the member is the day-to-day manager;
  • provide agency time sheets to the member and orient the member to the time sheet submission process, including how frequently time sheets must be completed;
  • receive and process attendant time sheets;
  • send new attendants within the required time frame to interview at the member's or LAR's request; and
  • orient the member or LAR to the agency's attendant evaluation process, including forms and the schedule for evaluating attendants.

 

5413 Member Responsibilities

Revision 20-1; Effective March 16, 2020

 

The member or legally authorized representative (LAR) 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 or LAR 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 or LAR’s behalf.

The member or LAR 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 service plan and works only the number of hours authorized in the service plan;
  • 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, addressing 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 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 meeting); and
  • notifying the MCO and agency supervisor if a change to either the agency option or Consumer Directed Services (CDS) is desired. A service planning team meeting will be held to plan for the change.

 

5420 Managed Care Organization 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, managed care organization procedures are not impacted by the member's choice of SRO. Complete all forms currently required and continue to identify any caregivers who are currently providing for the member's needs.

 

5421 Initial Authorization of Services

Revision 20-1; Effective March 16, 2020

 

The member's or legally authorized representative's decision to receive services using the Service Responsibility Option does not change the manner in which initial services are authorized. See Section 3300, Member Service Planning and Authorization, for specific information.

 

5422 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 will:

  • 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:

  • satisfaction with the SRO; and
  • ability to comply with SRO requirements.

If it is evident that the member is having difficulty in the management of SRO responsibilities, the MCO staff must:

  • consult the agency staff; and
  • advise the member of the option to transfer back to the agency option.

 

5423 Presentation of SRO

Revision 20-1; Effective March 16, 2020

The managed care organization (MCO) service coordinator must offer the Service Responsibility Option (SRO) upon enrollment and annually thereafter. Additionally, the SRO must be presented to the member or legally authorized representative (LAR) upon request. If the member is interested in transferring to the SRO, the member must sign Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

The MCO must ensure the member or LAR understands the responsibility he is assuming. Send Form H2067-MC, Managed Care Programs Communication, to the agency to advise it of the member's selection. Notify the agency the member will be contacting it for training. Request the agency to advise the MCO, using Form H2067-MC, when the transition planning is complete. Negotiate a start date with the member and the agency.

Section 6000, Denials and Disenrollment

Section 6000, Denials and Disenrollment rarefyev Thu, 03/23/2017 - 08:10
Body

Revision 20-3; Effective December 1, 2020

 

 

6050 Description

Revision 20-3; Effective December 1, 2020

 

Sections 6100 and 6200 provide information pertaining to denial of Medically Dependent Children Program (MDCP) services for active members, along with adequate notice of a member's rights and opportunities to due process.

Section 6300 provides information on member or managed care organization (MCO) requested disenrollment from the STAR Kids Program. 

1 Texas Administrative Code §353.1203, which is cited on Form H2065-D, Notification of Managed Care Program Services, is the basis for all STAR Kids case actions.

 

6100 Ten Business Day Adverse Determination Notification

Revision 20-3; Effective December 1, 2020

 

Texas Health and Human Services Commission (HHSC) requires a notice to be sent to the member at least 10 business days before the action effective date. The member must be given the full 10 business day adverse action period to allow time to file an MCO internal appeal or request an external medical review, and/or fair hearing, as described below:

(a) If the agency mails the 10 business day notice, or within the time frames specified, as required under 42 Code of Federal Regulations (CFR) §431.213 or §431.214, and the beneficiary requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing unless—

(1) It is determined at the hearing that the sole issue is one of Federal or State law or policy; and

(2) The agency promptly informs the beneficiary in writing that services are to be terminated or reduced pending the hearing decision.

The managed care organization (MCO) must calculate time periods related to adverse actions in accordance with instruction provided in §311.014 of the Code Construction Act. It specifies that:

(a) In computing a period of days, the first day is excluded and the last day is included.

(b) If the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday.

The 10 business 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 business day adverse action period requires 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 individual signs a statement to waive the adverse action period.

To ensure the member is provided the full 10 business day adverse action period, the MCOs must mail the adverse determination document no later than 10 business days prior to the date the adverse action is to occur.

 

6200 Denial/Termination of Medically Dependent Children Program

Revision 20-3; Effective December 1, 2020

 

Program level denials are initiated when the member does not meet one or more Medically Dependent Children Program (MDCP) eligibility criteria. 

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

  • Residence in a nursing facility for more than 90 days;
  • Member voluntary withdrawal; 
  • Medicaid financial eligibility;
  • Exceeding the cost limit;
  • Medical necessity (MN); or
  • Inability to locate the member.

The managed care organization (MCO) must:

  • monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for the MN denial notice; and
  • notify the Program Support Unit (PSU) of the reason for denial request by submitting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in accordance with the conventions identified in Chapter 16.2 of the Uniform Managed Care Manual. 

PSU will:

  • mail the member Form H2065-D; 
  • upload Form H2065-D to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions. 

 

6210 Denial/Termination Due to Death

Revision 20-3; Effective December 1, 2020

 

Within two business days of verification of the death of a member, Program Support Unit (PSU) staff will post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the managed care organization’s (MCO’s) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.


If a member's Medicaid eligibility has been denied due to death in the Texas Integrated Eligibility Redesign System (TIERS), the appropriate entries must be made to end enrollment in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal.

Services must be terminated once death of the member has been confirmed by PSU staff. 


A 10 business day adverse action period is not required for death denials.

 

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 20-3; Effective December 1, 2020

 

The process for members residing in a nursing facility (NF) (excluding Truman Smith*) is as follows:

  • For members enrolled in STAR Kids, the enrollment remains open while a member resides in an NF. 
    • For members with Supplemental Security Income (SSI) or SSI-related Medicaid, the member remains enrolled in STAR Kids but Medically Dependent Children Program (MDCP) services must be suspended per Section 3326, Suspension of Medically Dependent Children Program Services. 
    • For members without SSI or SSI-related Medicaid (i.e., medical assistance only (MAO) members), the member remains enrolled in STAR Kids but MDCP services must be suspended per Section 3326.
  • If a member enrolled in MDCP has resided in an NF for 90 days or more, the managed care organization (MCO) must notify Program Support Unit (PSU) staff within 14 days following the 90th day of residence. 
    • The MCO sends this notice to PSU staff by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Once a denial is complete, if a member decides to discharge from the NF, the member would be directed to pursue Money Follows the Person (MFP) found in Section 2100, Money Follows the Person.

*Members enrolled in STAR Kids who enter the Truman Smith NF or a state veteran's home are excluded from STAR Kids. STAR Kids and MDCP eligibility must be denied.

 

6230 Denial/Termination of Medicaid Financial Eligibility

Revision 20-3; Effective December 1, 2020

 

A member's continued receipt of STAR Kids services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or medical assistance only (MAO) program requirements.

The member is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI or Medicaid for the Elderly and People with Disabilities (MEPD) specialists for MAO. The individual may appeal the financial denial using SSA or MEPD processes, as appropriate.

Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

The chart below describes how to proceed if financial eligibility is denied.

 

When the individual is denied SSI: When the individual is denied MAO:
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to SSA is available to the individual.
  • The individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long-term services and supports (LTSS) (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.
  • Disenrollment from the STAR Kids program will occur effective the last date of Medicaid eligibility, which is usually the last day of the current or following month.
  • The right to appeal to MEPD is available to the individual.
  • The individual can contact the local HHSC office to request other LTSS (for example, Community Attendant Services, Family Care, Title XX programs or state-funded programs).
  • Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established according to the date of the request.

For SSI members, the termination date must match the SSA termination date.

For MAO members, the termination/denial date must match the MEPD MAO denial date. This is true even if the MAO denial date is in the past when PSU staff become aware of the denial.

6240 Denial/Termination as a Result of Exceeding the Cost Limit

Revision 20-3; Effective December 1, 2020

 

The Medically Dependent Children Program (MDCP) waiver is intended to serve individuals who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems in determining if the MDCP individual service plan (ISP) ensures the needs of the applicant or member. 


As part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or resource utilization group (RUG) value assigned by Texas Medicaid Healthcare Partnership (TMHP). HHSC expects this type of denial will occur rarely as MDCP members primarily receive state plan services.


When MDCP applicants or members exceed their assigned cost limit, the MCO must notify Program Support Unit (PSU) staff of the MDCP program denial request of MDCP and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial request is based on the inadequacy of the ISP, including both MDCP and non-MDCP services, to meet the needs of the individual within the RUG cost limit.

 

6250 Denial/Termination of Medical Necessity

Revision 20-3; Effective December 1, 2020

 

Medically Dependent Children Program (MDCP) services must be denied when an applicant or member fails to meet medical necessity (MN) criteria.

Notification can come from:

  • the monthly individual service plan (ISP) expiring report;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

The MCO must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for notification of a preliminary denial of medical necessity “MN Pending Denial.”


When the MN status is in the “MN Pending Denial” status, the MCO must: 

 

  • Verify with the TMHP nurse assessor what information is missing for MN;
  • Review Form 2605, Member SK-SAI MDCP Review Signature, Question 8. 
    • If the answer on Form 2605 is marked “Yes”:
      • Contact the member or Legally Authorized Representative (LAR) to confirm the request to have a peer-to-peer review;
      • Contact the listed physician of choice on Form 2605 to schedule and complete a peer-to-peer review; 
      • Submit any information obtained during the review to TMHP to support MN; and
      • Continue the denial process as outlined below.
    • If the answer on Form 2605 is marked “No”:
      • Contact the member or LAR and offer an opportunity to hold a peer-to-peer review with the treating physician of the member’s or LAR’s choice and the MCO medical director. 
      • If the member/LAR requests the peer-to-peer review:
        • Verify the physician of the member’s/LAR’s choice,
        • Contact the physician of the member’s/LAR’s choice to schedule and complete a peer-to-peer review; 
        • Submit any information obtained during the review to TMHP to support MN; and
        • Continue the denial process as outlined below.
      • If the member/LAR refuses the peer-to-peer review:
        • Document the refusal in the member’s file; and
        • Continue the MN denial process as outlined below.
           

The peer-to-peer review should cover specifically those items on the STAR Kids Screening and Assessment Instrument (SK-SAI) related to MN. The MCO must ensure that the member’s/LAR’s physician of choice has access to the completed SK-SAI before the peer-to-peer review. 

Any information obtained in the peer-to-peer review must be submitted to TMHP. 

The MCO is required to ensure that the peer-to-peer review does not affect member rights to appeal an initial assessment or reassessment through the MCO internal appeal process or the state fair hearing process. 

In addition, the MCO must monitor the TMHP portal through the final MN determination.

The MN status of "MN Denied" in the TMHP LTC Online Portal is the period when the MDCP waiver applicant's or member's physician has 14 business days to submit additional information. Once an SK-SAI MN status is in "MN Denied" status, several actions may follow:

  • MN Approved: The status changes to "MN Approved" if the TMHP doctor 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 doctor to overturn the denied MN has expired. No additional information was submitted for the doctor review. The denied MN remains in this status unless a fair hearing is requested; or
  • Doctor Overturn Denied: The status changes to "Doctor Overturn Denied" when additional information is received but the TMHP doctor does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

While the MN is in the MN Denied status, the MCOs must monitor the TMHP LTC Online Portal for the MN status through completing a current activity or Form Status query in the TMHP LTC Online Portal every seven days, at a minimum.

If a member’s MN status enters the period when the MDCP waiver applicant or member’s physician has 14 business days to submit additional information, listed in the TMHP LTC Online Portal as “MN Denied,” the MCO must assist the member to obtain from their physician any additional medical information pertinent to the member’s MN determination. The MCO must assist through calling the member and physicians to obtain necessary documents for provision to TMHP within the 14 business day time frame for consideration.

 

6260 Denial/Termination Due to Inability to Locate the Member

Revision 20-3; Effective December 1, 2020

 

The Medically Dependent Children Program (MDCP) must be denied when Program Support Unit (PSU) staff are notified that a member cannot be found.

Prior to notifying PSU, the managed care organization (MCO) must make at least three efforts to contact members 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. 

Notification can come from:

  • monthly reports;
  • Managed Care Compliance Operations (MCCO);
  • an MCO; or
  • other reliable sources.

 

6270 Denial/Termination Due to Failure to Meet Other Program Requirements

Revision 20-3; Effective December 1, 2020

 

Use this denial citation if the applicant or member does not meet a Medically Dependent Children Program (MDCP) requirement mentioned in Sections 6210 through Section 6260 above. For example, this citation would be used if the applicant or member does not require at least one service. Within two business days of the denial, Program Support Unit (PSU) staff must:

  • send the applicant or member Form H2065-D, Notification of Managed Care Program Services; and
  • post Form H2065-D to TxMedCentral in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

 

6280 Denial/Termination for Other Reasons

Revision 18-2; Effective September 3, 2018

 

Use this citation if initiating denial or termination for a reason not covered in Sections 6210 through Section 6270. Within two business days of the denial, Program Support Unit (PSU) staff must:

  • send the member Form H2065-D, Notification of Managed Care Program Services; and
  • post Form H2065-D to TxMedCentral in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Notification can come from:

  • monthly reports;
  • Enrollment Resolution Services (ERS);
  • an MCO; or
  • other reliable sources.

 

6300 Disenrollment from Managed Care

Revision 20-3; Effective December 1, 2020

 

Texas Health and Human Services Commission (HHSC) conducts member disenrollment activities. Although a STAR Kids 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 353.1201 and 353.1203 (related to STAR Kids 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 the STAR Kids Medically Dependent Children Program (MDCP) waiver may also lose some, if not all, of their MDCP waiver services in the transition to FFS Medicaid.  

 

6310 Disenrollment Request by the Managed Care Organization

Revision 20-3; Effective December 1, 2020

 

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 C.F.R. § 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 7000, Complaint, Appeal and Fair Hearing Procedures

Section 7000, Complaint, Appeal and Fair Hearing Procedures rarefyev Thu, 03/23/2017 - 10:52
Body

Revision 17-1; Effective June 1, 2017

 

 

7100 Managed Care Organization Procedures

Revision 17-1; Effective June 1, 2017

 

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 42 Code of Federal Regulations (CFR) §431.200; 42 CFR Part 438, Subpart F, Grievance System; and the provisions of 1 Texas Administrative Code Chapter 357, relating to Medicaid MCOs.

The MCO's complaint and appeal system must include:

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

 

7110 Managed Care Organization Complaint Procedures

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission's (HHSC) STAR Kids Contract, 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 42 C.F.R. §438.400, possible subjects for complaints include the quality of care of services provided, 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 members want to file a complaint, they must first contact the MCO, following procedures specified in the MCO's member handbook. The MCO must provide designated member advocates to:

  • assist members in using the complaint system:
  • assist members in writing or filing a complaint; and
  • monitor the complaint throughout the process until the issue is resolved.

In addition to filing complaints with the MCO, a STAR Kids member may file complaints with the state of Texas. If a STAR Kids member contacts the MCO or any HHSC employee with a complaint regarding an agency licensed by HHSC, or any other state agency, the member is referred to 1-800-458-9858 to file a regulatory complaint. If the complaint is initially received by HHSC, HHSC will inform the MCO of the complaint.

Members may also call the HHSC Ombudsman's Managed Care Assistance Team at 1-866-566-8989 for assistance filing a complaint not related to licensure issues.

 

7120 Managed Care Organization Internal Appeal Procedures

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) STAR Kids Contract, Attachment A, defines an appeal as the formal process by which a member or his or her authorized 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 internal 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 related to the actions listed above as an appeal. The MCO must provide a designated member advocate to assist the member in filing an appeal. The advocate must also assist members or authorized representatives by monitoring the appeal throughout the process until the issue is resolved.

During the internal appeal process, the MCO must provide the member or an authorized representative 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 or the authorized representative of the time available for providing this information.

The MCO must provide the member and his or her authorized 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 internal appeal if all the following criteria are met:

  • The member or his or her authorized representative files the internal appeal timely, as defined in the STAR Kids contract.
  • The appeal involves the termination, suspension or reduction of a previously authorized course of treatment.
  • The services were ordered by an authorized provider.
  • The original period covered by the original authorization has not expired.
  • The member requests an extension of the benefits.

 

7121 Expedited Managed Care Organization Internal Appeals

Revision 17-1; Effective June 1, 2017

 

In accordance with 42 Code of Federal Regulations §438.410 and STAR Kids Contract, Attachment B-1, Section 8.1.29.3, the managed care organization (MCO) must establish and maintain an expedited review process for service-related internal 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 internal appeal requirements for standard member internal appeals as set forth in the STAR Kids contract, Attachment B-1, Section 8.1.29.2, except where differences are specifically noted. The MCO must accept oral or written requests for expedited internal appeals.

After the MCO receives a request for an expedited internal appeal, the MCO must notify the member or his or her authorized representative of the outcome of the expedited internal appeal request within three business days. However, the MCO must complete investigation and resolution of an internal 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 an expedited internal appeal.

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

Except for an internal appeal relating to an ongoing emergency or denial of continued hospitalization, the time frame for notifying the member of the outcome of the expedited internal appeal may be extended up to 14 calendar days if the member requests an extension or the MCO shows (to the satisfaction of the Texas Health and Human Services Commission (HHSC), upon HHSC’s request) 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 determination is adverse to the member, the MCO must follow the procedures relating to the notice in the STAR Kids Contract, Attachment B-1, Section 8.1.29.5. The MCO is responsible for notifying the member of his or her right to access a state fair hearing from HHSC. The MCO is responsible for providing documentation to the state and the member, indicating how the determination was made, prior to HHSC’s fair hearing.

The MCO is prohibited from discriminating or taking punitive action against a member or his/her representative for requesting an expedited internal appeal. The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports a member’s request.

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

  • transfer the appeal to the time frame for standard internal 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.

 

7200 State Fair Hearing Procedures for Medically Dependent Children Program

Revision 17-1; Effective June 1, 2017

 

 

7210 Program Support Unit Procedures

Revision 17-1; Effective June 1, 2017

 

When a request for a state fair hearing related to Medically Dependent Children Program (MDCP) eligibility is received from an applicant or member, orally or in writing, Program Support Unit (PSU) staff must refer the request to the Texas Health and Human Services Commission Appeals Division within five calendar days from the date of the request. Upon receipt of the fair hearing request, PSU staff complete Form H4800, Fair Hearing Request Summary. The PSU staff either:

  • send the form to the regional data entry representative (DER) within three calendar days of the request for a hearing, which allows the DER two days to enter the information into the Texas Integrated Eligibility Redesign System (TIERS); or
  • enter the request for a fair hearing into TIERS, ensuring it is entered within five calendar days from the date of the request.

Form H4800 records 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. PSU staff should contact the MCO if there is doubt as to who should be listed on Form H4800.

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

  • MCO (whenever possible, this should be the individual who completed the assessment) and Texas Medicaid & Healthcare Partnership (TMHP) (for medical necessity 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).

When PSU staff complete Form H4800, 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 ISP 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 state fair hearing so the hearings officer is aware of when the ISP year ends when rendering a hearing decision regarding the MDCP waiver denial.

The format for Form H4800 follows the data entry screens. See the form instructions for more specific directions for completion and transmittal.

 

7211 Designated Data Entry Representative Procedures

Revision 17-1; Effective June 1, 2017

 

Within two calendar days of receipt of Form H4800, Fair Hearing Request Summary, the data entry representative (DER) enters the information into the Hearings and Appeals section of the Texas Integrated Eligibility Redesign System (TIERS). 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 Program Support Unit staff.

 

7212 Fair Hearings and Appeals Procedures

Revision 17-1; Effective June 1, 2017

 

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

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

 

7213 Evidence Packet

Revision 17-1; Effective June 1, 2017

 

All related documentation necessary to support the determination on an appeal must be uploaded into the State Portal and mailed to the appellant at least 10 business days prior to the hearing. Each entity involved in the action taken is responsible for preparing its evidence packet, uploading it to the State Portal, and forwarding it to the appellant. All documentation must be neatly and logically organized, and all pages numbered.

The following are examples of documentation that may be submitted as evidence and the entity responsible for uploading that information to the State Portal:

  • Managed care organization (MCO):
    • MCO policy handbook, STAR Kids Handbook and/or STAR Kids contract/STAR Kids Managed Care Manual;
    • summary of events;
    • other documentation supportive of the determination, such as documentation of telephone calls and visit summaries; and
    • copies of the signed Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and all relevant attachments;
  • Medicaid for the Elderly and People with Disabilities Centralized Representation Unit:
    • documentation supportive of the financial determination, including official documentation forms and telephone calls; and
    • a copy of the original signed denial form;
  • Texas Medicaid & Healthcare Partnership (TMHP):
    • a copy of the STAR Kids Screening and Assessment Instrument (SK-SAI); and
    • other documentation supporting the determination; and
  • Program Support Unit: 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 state appeal was filed).

 

7214 Fair Hearing Request Summary (Addendum)

Revision 17-1; Effective June 1, 2017

 

After the data entry representative (DER) or Program Support Unit (PSU) staff has added information from Form H4800, Fair Hearing Request Summary, 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 state fair hearing. When this occurs, PSU staff complete Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submit it to the designated DER who will check TIERS to identify if a hearings officer has been assigned to the case. In the event the updates need to be communicated to the hearings officer, PSU staff complete and forward Form H4800 to the DER.

If a 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 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 a state appeal, the DER not only emails Form H4800-A to the assigned hearings officer, but also uploads the supporting documentation directly into the State Portal. 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 the State Portal.

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

 

7220 Special Procedures for Cases – Medicaid for the Elderly and People with Disabilities or Texas Works Determined Financial Eligibility

Revision 17-1; Effective June 1, 2017

 

 

7221 Centralized Representation Unit

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) Medical and Social Services (MSS) maintain 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 staff in specific steps related to the denial of MEPD applications and ongoing cases. The CRU:

  • represents HHSC MSS in state fair hearings, which includes both TW and MEPD;
  • completes and implements all TW/MEPD case actions based on fair hearing decisions for all appeals initiated by the CRU; and
  • coordinates actions required with TW/MEPD and Program Support Unit (PSU) staff.

PSU staff must coordinate all state appeals involving TW/MEPD-related eligibility with CRU, including Medically Dependent Children Program (MDCP) waiver cases. The procedures in Section 7222 below must be used to coordinate state appeal actions with CRU in cases for which TW or MEPD staff determine financial eligibility. All correspondence on state appeals will go to the CRU supervisor and the CRU administrative assistant.

 

7222 Program Support Unit Procedures

Revision 17-1; Effective June 1, 2017

 

Program Support Unit (PSU) staff are responsible for completing Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when an applicant/member requests a state fair hearing. For state appeals that involve the Centralized Representation Unit (CRU), the method in which the form is completed depends on the action being appealed. PSU staff must determine if the appealed action is a:

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

If the appealed action is related to an MEPD waiver denial based on an eligibility factor other than financial, PSU staff complete Form H4800, entering the managed care organization (MCO) contact as the agency representative.

If the appealed action is related to an MDCP waiver denial based on a TW/MEPD financial denial, PSU staff complete Form H4800 and enter the name of the PSU staff person who will appear at the fair hearing as the agency representative. This information must be entered through the Manage Office Resources (MOR) search function for the PSU staff person to receive the hearing information.

For members requesting continued benefits and who are part of the Medical Assistance Only eligibility group, when Form H4800 is sent to the designated data entry representative, PSU staff send an email notification regarding the request for a state fair hearing to CRU. PSU staff 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- 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 (MDCP waiver); and
  • specific information requesting TW/MEPD financial case remain active/open during the state fair hearing, 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.

When an MDCP waiver denial fair hearing decision is rendered by the hearings officer, the PSU staff are notified via email of the decision by the hearings officer. Based on the hearing decision, PSU staff determine the appropriate action for the waiver according to program-specific time frames. For more information, refer to Section 7500, Hearing Decision Actions.

PSU staff may need to coordinate effective dates of reinstatement with CRU and must send an email to the HHSC OES Fair Hearings mailbox, and include Form H1746-A, MEPD Referral Cover Sheet. PSU staff report the implementation of the hearing decision through TIERS Decision Implementation.

If a member appeals a Medicaid denial issued by the TW or MEPD program, the CRU enters the fair hearing request in TIERS and notifies PSU the applicant/member appealed the Medicaid denial by sending an email to the PSU supervisor and backup designee. When notifying the PSU, CRU staff use the following subject line: "URGENT: STAR Kids member appealed financial denial of MDCP program. MCO Plan Code XX (if available)." The CRU processes the fair hearing request of the Medicaid denial following established procedures. CRU does not list the MCO or PSU staff on the fair hearing request.

Within two business days of receiving the notice the applicant or member is appealing the financial denial, the PSU contacts the applicant or member, or his or her authorized representative, to determine whether he or she wants to appeal the MDCP program denial. If so, PSU staff process the fair hearing request following established procedures.

For TW/MEPD appeals, once the appeal decision regarding the MEPD financial case is rendered by the hearings officer, CRU must notify PSU staff by sending an email to the PSU supervisor and backup designee of the hearing decision, including decisions that are sustained, reversed or withdrawn. Based on the hearing decision, PSU staff determine the appropriate action for the MDCP waiver. The email sent by CRU includes the:

  • applicant's/member's name;
  • TIERS case number; and
  • copy of the hearing decision.

If Medicaid eligibility will be denied, the CRU includes the effective date of the Medicaid denial in the email. If Medicaid eligibility will be reinstated, the PSU must send the CRU an email with Form H1746-A to the HHSC OES Fair Hearings mailbox, indicating all other eligibility criteria are in place and Medicaid needs to be reestablished. The CRU will respond to the PSU by sending an email to the PSU supervisor and backup designee with the effective date of Medicaid eligibility.

PSU staff must not put an applicant/member back on the MDCP waiver interest list while a TW/MEPD denial is in the state 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 MDCP waiver interest list once staff deny the waiver.

 

7230 Evidence Packet and Hearing Decision

Revision 17-1; Effective June 1, 2017

 

 

7231 Uploading the Appeals Evidence Packet into the State Portal

Revision 17-1; Effective June 1, 2017

 

All evidence packets must be uploaded into the State Portal 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 hearings officer. The appeal identification number assigned by Texas Integrated Eligibility Redesign System (TIERS) must be written on the top of Form H4800-A.

At least 12 business days prior to the fair hearing date, the Program Support Unit staff must:

  • scan 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 State 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.

 

7232 Presentation of the Evidence Packet

Revision 17-1; Effective June 1, 2017

 

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The Program Support Unit (PSU) staff and supervisors 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 state fair hearings.

Documentation contained in the evidence packet is not considered in the hearing decision unless the packet is offered and admitted into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be admitted 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 2603, STAR Kids, Individual Service Plan (ISP) Narrative. Pages 11-15 contain policy from the STAR Kids 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, 2016."

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

 

7233 Hearing Decision

Revision 17-1; Effective June 1, 2017

 

After the hearing, the hearings officer sends a hearing decision to the appellant and copies to individuals listed on Form H4800, Fair Hearing Request Summary, which includes Program Support Unit (PSU) staff. If the determination on appeal is sustained, the PSU staff take the appropriate action. If the member requested continued services during the state appeal period, the PSU follows procedures described in Section 7500, Hearing Decision Actions.

If the determination on appeal is reversed, the hearings officer specifies the corrective action to be taken and a 10-day time frame for completion of the action. PSU staff actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation, within the 10-day time frame designated by the hearings officer.

 

7300 Post Hearing Actions

Revision 17-1; Effective June 1, 2017

 

 

7310 Action Taken on the Hearing Decision

Revision 17-1; Effective June 1, 2017

 

Program Support Unit (PSU) staff complete Form H4807, Action Taken on Hearing Decision, recording case actions taken and send it to the designated data entry representative (DER). PSU staff must send Form H4807 within the time frame specified by the hearings officer 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 H4807 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.

 

7400 Continuation of Services

Revision 17-1; Effective June 1, 2017

 

 

7410 Continuation of Medically Dependent Children Program Waiver Services During a State Appeal

Revision 17-1; Effective June 1, 2017

 

Medically Dependent Children Program (MDCP) waiver services must continue until the hearings officer issues a decision regarding the appeal of an active MDCP waiver member, if the appeal is filed by the effective date of the action pending the appeal. If a state appeal was requested by the effective date of the action, Program Support Unit (PSU) staff must promptly notify the managed care organization (MCO) by posting Form H2067-MC, Managed Care Programs Communication, to the MCO via TxMedCentral and uploading a copy of this form in the HHS Enterprise Administrative Record Tracking (HEART) system.

If the member requests continued benefits, MDCP waiver services must continue to be provided until the hearings officer renders a decision. The PSU includes this information on Form H2067-MC posted on TxMedCentral.

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 state appeal is determined. PSU staff 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 issued.

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

 

7420 Discontinuation of Medically Dependent Children Program Waiver Services During a State Fair Hearing

Revision 17-1; Effective June 1, 2017

 

If a state fair hearing is not requested by the effective date of the action, Medically Dependent Children Program (MDCP) waiver 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). The Program Support Unit (PSU) must complete Form H2067-MC, Managed Care Programs Communication, and process according to the following:

  • For Medical Assistance Only (MAO) members, Form H2067-MC is:
    • posted to TxMedCentral to inform the managed care organization (MCO) MDCP waiver services must continue until the end of the ISP period or the Medicaid denial date, as notated on Form H2065-D; and
    • emailed to Enrollment Resolution Services to disenroll from STAR Kids following the disenrollment policy effective the day immediately following the ISP expiration date for MAO MDCP members only.
  • For Supplemental Security Income (SSI) members, Form H2067-MC should be posted to TxMedCentral to inform the MCO that MDCP waiver services should only continue until the effective date of the action, which is usually the expiration date of the ISP.

SSI members are still enrolled in a STAR Kids MCO and are still eligible for State Plan services, which include acute care and long term services and supports, such as Personal Care Services, Day Activity and Health Services, and Community First Choice Services.

 

7500 Hearing Decision Actions

Revision 17-1; Effective June 1, 2017

 

 

7510 Sustained Appeal Decisions

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision sustains the denial of Medically Dependent Children Program (MDCP) waiver 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 by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral, to deliver services through the MDCP waiver termination effective date if services were continued during the state fair hearing process;
  • terminate MDCP services by end-dating the individual service plan (ISP) in the Texas Medicaid & Healthcare Partnership (TMHP) portal effective the MDCP termination effective date;
  • send an 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, notifying the Centralized Representation Unit (CRU) of the hearings officer's decision and the termination effective date for non-Supplemental Security Income(SSI) recipients; and
  • notify Enrollment Resolution Services (ERS) of the hearings officer's decision and the termination effective date for non-SSI recipients. ERS disenrolls non-SSI recipients from STAR Kids.

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

 

7511 Sustained Decisions – Termination Effective Dates

Revision 17-1; Effective June 1, 2017

 

When services are terminated at reassessment because the member does not meet eligibility criteria and services are continued until the state fair hearing decision is known, the Medically Dependent Children Program (MDCP) waiver termination effective date will vary depending on the following 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 state fair hearing was filed, MDCP waiver termination is effective at the end of the ISP in effect at the time the state fair hearing 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 state fair hearing 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). See Example 2.
  • When the hearings officer's decision date is after the end of the ISP in effect when the state fair hearing 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. See Example 3.
  • If the hearings officer assigns a specific medical necessity (MN) expiration date not equal to the last day of the month but after the end of the ISP in effect when the state fair hearing 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 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 state fair hearing was filed, the termination effective date is the end of that ISP period. See Example 5.
  • If the hearings officer assigns a specific MN expiration date that is before the end of the MN in effect when the state fair hearing was filed, the termination effective date is the end of the month of the original MN 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. 1/31/16 5/31/16 11/30/15 1/31/16
2 Hearings officer decision is less than 30 days from the original expiration date. 1/31/16 5/31/16 1/15/16 2/28/16
3 Hearings officer decision is greater than the original ISP expiration date and less than the new expiration date. 1/31/16 5/31/16 2/15/16 3/31/16
4 Hearings officer decision assigns a specific expiration date. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 2/15/16. 2/29/16
5 Hearings officer decision assigns a specific expiration date that occurs in the future. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 2/29/16. 2/29/16
6 Hearings officer decision assigns a specific expiration date that occurred in the past. 1/31/16 5/31/16 Hearings officer decision was for MN to expire on 12/31/15. 1/31/16

 

7520 Reversed Appeal Decisions

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision reverses the denial of a Medically Dependent Children Program (MDCP) waiver applicant or member, Program Support Unit (PSU) staff must:

  • notify the managed care organization (MCO) via Form H2067-MC, Managed Care Programs Communication, that MDCP waiver services are to continue as directed in the hearings officer's decision and to request Form 2603, STAR Kids Individual Service Plan (ISP) Narrative;
  • send Form H2065-D, Notification of Managed Care Program Services, within two business days to the:
    • member who was terminated at reassessment to notify him the denial determination was reversed and he is eligible for MDCP waiver services for the new individual service plan (ISP) year;
    • applicant who was denied at application to notify him of eligibility for MDCP waiver services;
    • MCO regarding applicants and members at reassessment of the MDCP waiver effective date; and
    • Enrollment Resolution Services staff regarding applicants and the MDCP waiver effective date and enrollment date; and
  • ensure the ISP is registered or updated in the Long Term Care online portal with the correct effective dates; and
  • send an email with Form H1746-A, MEPD Referral Cover Sheet, to the Texas Health and Human Services (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, notifying the Centralized Representation Unit (CRU) of the hearings officer's decision and the member meets all eligibility criteria for the MDCP waiver, for non-Supplemental Security Income recipients. The CRU will respond to the PSU by sending an email to the PSU supervisor and backup designee with the effective date of Medicaid eligibility.

 

7521 Reversed Decisions – Effective Dates

Revision 17-1; Effective June 1, 2017

 

When the hearings officer’s decision reverses the denial of Medically Dependent Children Program (MDCP) waiver eligibility, the MDCP waiver effective date for:

  • reassessment is one day after the end of the individual service plan in effect when the state fair hearing was filed; and
  • MDCP waiver denied at application is the first of the month following the hearings officer's 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 the Implementation Delays screen in the Texas Integrated Eligibility Redesign System (TIERS), Decision Implementation.

 

7522 New Assessment Required by Fair Hearing Decision

Revision 17-1; Effective June 1, 2017

 

If the hearings officer’s final decision orders completion of a new STAR Kids Screening and Assessment Instrument (SK-SAI), 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. If the new assessment results in a denied medical necessity (MN), 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 H4800, Fair Hearing Request Summary, that the new assessment was ordered from a previous fair hearing decision.

If the member requests a state fair hearing 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 Medically Dependent Children Program (MDCP) waiver member is denied 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 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 continues 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.

 

7523 Request to Withdraw an Appeal

Revision 17-1; Effective June 1, 2017

 

An appellant or appellant representative must request to withdraw his appeal by sending written notice to the hearings office. The hearings office cannot accept an oral request to withdraw his or her appeal. If the appellant or appellant representative contacts Program Support Unit (PSU) staff regarding a withdrawal, PSU staff must advise the appellant or the appellant's representative the request to withdraw the appeal must be a written notice to the hearings office. If the appellant or appellant's representative sends a written request to withdraw to PSU staff, PSU staff must forward this written request to the hearings office. All requests to withdraw the hearing must originate from the appellant or appellant representative and must be made to the hearings office.

If the appellant or appellant's 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's representative requests to withdraw his state 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 will send a written notice to participants informing them of the fair hearing cancellation.

 

7600 Roles and Responsibilities of Texas Health and Human Services Commission Hearing Officers

Revision 17-1; Effective June 1, 2017

 

The Texas Health and Human Services Commission (HHSC) hearings officer:

  • notifies all persons listed on Form H4800, 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 a state 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.

 

7700 Fair Hearings for Managed Care Organization Determinations

Revision 17-1; Effective June 1, 2017

 

If an applicant wishes to request a fair hearing with the state of Texas regarding a Medically Dependent Children Program (MDCP) waiver 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 MDCP waiver member may also request a state fair hearing by contacting PSU.

Section 8000, Utilization Management and Review by the State

Section 8000, Utilization Management and Review by the State rarefyev Thu, 03/23/2017 - 14:59
Body

Revision 19-1; Effective June 3, 2019

 

 

8100 Utilization Review Purpose

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 Kids managed care organizations (MCOs) must make information including, but not limited to, documents, assessments, notes and authorizations regarding STAR Kids members available upon request from UR. STAR Kids MCOs must participate and make appropriate staff available for reviews conducted by UR upon request from that division.

Appendices

Appendices rarefyev Thu, 03/23/2017 - 15:52

Appendix II, Long Term Services and Support Billing Procedures

Appendix II, Long Term Services and Support Billing Procedures rarefyev Tue, 03/28/2017 - 11:35
Body

6-2017

 

The managed care organization (MCO) must require all providers rendering Long-Term Services and Support (LTSS), with the exception of atypical providers, to use the CMS 1500 Claim Form or the HIPAA 837 Professional Transaction when billing. Atypical providers are LTSS providers that render non-health or non-medical services to STAR+PLUS members.  Examples include pest control services and building and supply services.
 
Providers using the Paper CMS 1500

Providers billing on paper will provide complete information about the service event and will use the state assigned provider identification (ID) to represent the provider(s) involved in the service event. The provider ID (billing and/or rendering) will be located in Block 33 on the paper form.

  • If the billing provider and the rendering provider are the same, then the state assigned provider ID will be populated in Block 33.
  • If the rendering provider is different than the billing provider, then the billing provider state assigned provider ID will be populated in Block 33, and the rendering provider state assigned provider ID will be populated in Block 24K.
  • Under specific scenarios, the additional usage of Block 17a (Referring Provider (Optional)) and Block 24k can be used to report additional information on providers that are involved in the service event.

Providers using the Electronic HIPAA 837

Providers billing electronically will comply with HIPAA 837 guidelines, including the accurate and complete conveyance of information pertaining to the provider(s) involved in the service event.
 
Atypical Providers

Atypical providers will submit appropriate documentation to the MCO.  The MCO must obtain sufficient documentation from the atypical provider to accurately populate an 837 professional encounter. Refer to the HIPAA-compliant 837 Professional Combined Implementation Guide and the 837 Professional Companion Guide for further information. (See “Claims Processing Requirements” in §2, Claims, in the UMCM.)

Providers and MCOs will bill and report LTSS in compliance with the STAR Kids Billing Matrix (Matrix).

Providers – LTSS providers must use the “designated position” of the modifiers, as indicated on the Matrix, when filing claims.

MCOs – MCOs must use the “designated position” of the modifiers, as indicated on the Matrix, when reporting encounters.

Nursing Facilities (NFs) – Services pertaining to a member entering a nursing facility will be filed (paper or electronic) through the state’s claims administrator under traditional Medicaid (fee for service) following the claims submission guidelines applicable to traditional Medicaid billing. Services that do not involve a member entering a nursing facility (i.e., respite care) will conform to normal LTSS billing procedures.

The LTSS Bulletin posted on the Texas Medicaid Health Partnership website (www.tmhp.com) provides additional information and updates.

Appendix III, LTSS Billing Matrix and Crosswalk

Appendix III, LTSS Billing Matrix and Crosswalk rarefyev Tue, 03/28/2017 - 13:25

Appendix IV, MDCP Frequently Asked Questions

Appendix IV, MDCP Frequently Asked Questions rarefyev Tue, 03/28/2017 - 15:16

Appendix V, Acronyms

Appendix V, Acronyms rarefyev Tue, 03/28/2017 - 15:22

Appendix VI, STAR Kids Transition Activities

Appendix VI, STAR Kids Transition Activities rarefyev Tue, 03/28/2017 - 15:42

Appendix VIII, RUG IPC Cost Limits

Appendix VIII, RUG IPC Cost Limits rarefyev Wed, 03/29/2017 - 10:17

Appendix IX, STAR Kids TxMedCentral Naming Conventions

Appendix IX, STAR Kids TxMedCentral Naming Conventions rarefyev Wed, 03/29/2017 - 11:24

Appendix X, Monthly Income/Resource Limits

Appendix X, Monthly Income/Resource Limits rarefyev Tue, 04/11/2017 - 16:09

Appendix XI, STAR Kids Plan Codes

Appendix XI, STAR Kids Plan Codes acarreras Wed, 02/13/2019 - 11:42

Appendix XII, Mutually Exclusive Services

Appendix XII, Mutually Exclusive Services acarreras Wed, 04/01/2020 - 13:28

Appendix XIII, State Cutoff Dates

Appendix XIII, State Cutoff Dates mmeitl Mon, 07/26/2021 - 13:53

Upcoming Form Revisions

Upcoming Form Revisions Anonymous (not verified) Tue, 10/17/2017 - 14:56
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

Forms

Forms rarefyev Thu, 03/30/2017 - 09:47
Body

ES = Spanish version available.

Form Title  
0003 Authorization to Furnish Information  
1579 Referral for Relocation Services  
1581 Consumer Directed Services 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 Acknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
1740 Service Backup Plan ES
1741 Corrective Action Plan ES
1747 Acknowledgement of Nursing Requirements  
1826-D Case Information Release  
2406 Physician Recommendation for Length of Stay in a Nursing Facility ES
2416 Minor Home Modifications and Adaptive Aids Service Authorization  
2442 Notification of Interest List Release Closure ES
2601 Physician Certification ES
2602 Application Acknowledgment ES
2603 STAR Kids Individual Service Plan (ISP) Narrative ES
2604 STAR Kids Individual Service Plan - Service Tracking Tool ES
2605 Member SK-SAI MDCP Review Signature ES
3618 Resident Transaction Notice  
H1097 Affidavit for Citizenship/Identity ES
H1746-A MEPD Referral Cover Sheet  
H2053-B Health Plan Selection ES
H2065-D Notification of Managed Care Program Services ES
H2067-MC Managed Care Programs Communication  
H1200 Application for Assistance – Your Texas Benefits  
H3034 Disability Determination Socio-Economic Report ES
H3035 Medical Information Release/Disability Determination 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  

Glossary

Glossary rarefyev Thu, 03/30/2017 - 09:53
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. Exception: Some services for children are considered chronic and are covered under the State Medicaid Plan.

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 individuals 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 regulations that govern 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 STAR Kids 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.

Comprehensive Care Program (CCP) — A package of Medicaid services available to individuals based on medical necessity that goes beyond regular Medicaid services for all ages and is part of the Texas Health Steps benefit for individuals under age 21.

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 Kids 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.

Day — 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.

Early and periodic screening, diagnosis and treatment (EPSDT) — Federally mandated Early and Periodic Screening, Diagnosis and Treatment program contained at 42 U.S.C. 1396d(r). The name has been changed to Texas Health Steps (THSteps) in the state of Texas.

Eligibility date — The first date all eligibility criteria are met.

Employee (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 an 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.

Guardian — A person appointed as a guardian of the estate or of the person by a court.

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) narrative — An individualized and person-centered plan in which a member enrolled in the STAR Kids and community-based services 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.

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 legal or 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, guardian, 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.

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.

Medically Dependent Children Program (MDCP) — A §1915(c) waiver program which provides respite, Flexible Family Support Services, minor home modifications, adaptive aids, Transition Assistance Services, and FMS to prevent placement of individuals in long-term care facilities who are medically dependent and under age 21 and support deinstitutionalization of nursing facility residents under age 21.

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 Kids 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 Kids program before leaving the NF.

Plan of care (POC) — A care plan the MCO develops for its members that includes acute care and long-term services and supports (LTSS). The POC is not the same as the ISP service tracking tool used for MDCP services.

Program Support Unit (PSU) — An HHSC unit with staff who support and handle certain aspects of the STAR Kids program.

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.

Respite services — Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.

Responsible adult — An adult, as defined by Texas Family Code §101.003, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is age 18 years or older, the responsible adult must be the participant's managing conservator or legal guardian.

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 Kids members.

Service Plan – A POC developed by the MCO service coordinator authorizing tasks to be performed by the service provider (e.g., ISP).

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 program — 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.

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. Most individuals receiving SSI who are under the age of 21 are eligible for Medicaid and are required to enroll in STAR Kids.

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 agency 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 also responsible for processing Medical Necessity and Level of Care (MN/LOC) Assessments for the MDCP waiver and CFC.

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.

Texas Health Steps (THSteps) — The name adopted by the state of Texas for the federally mandated EPSDT program.

TxMedCentral — A secure internet bulletin board the state and MCOs use to share information.

Revisions

Revisions rarefyev Thu, 03/30/2017 - 09:55

21-2, Adds Appendix XIII

21-2, Adds Appendix XIII mmeitl Mon, 07/26/2021 - 17:11
Body

Revision Notice 21-2; Effective July 28, 2021

 

The following change(s) were made:

Section Title Change
Appendix XIII State Cutoff Dates Describes the state cutoff process and includes a state cutoff chart.

21-1, Adds Section 4822

21-1, Adds Section 4822 acarreras Wed, 12/16/2020 - 15:11
Body

Revision Notice 21-1; Effective April 1, 2021

 

The following change(s) were made:

Revised Title Change
4822 Time Frames for Minor Home Modifications Adds a new section to minor home modification policy to clarify the time frame for completion of minor home modifications.

20-3, Changes to Sections 2030, 6000, 6200, 6300 and Appendix III; Adds Form 2605

20-3, Changes to Sections 2030, 6000, 6200, 6300 and Appendix III; Adds Form 2605 mmeitl Thu, 11/05/2020 - 07:49
Body

Revision Notice 20-3; Effective December 1, 2020

 

The following change(s) were made:

Revised Title Change
2030 Managed Care Organization Coordination Updates requirements of Senate Bill 1207, Member SK-SAI MDCP review signature form. Adds headings and forms detail.
6000 Denials and Disenrollment Updates description of section to include the disenrollment policy, updates Texas Administrative Code (TAC) references and the adverse benefit notification to 10 business days. Removes the Program Support Unit (PSU) tables and procedures. Deletes Sections 6110, 6120, 6130 and 6140.
6200 Denial/Termination of Medically Dependent Children Program Clarifies denial reasons to program level denials and updates managed care organization (MCO) and PSU coordination procedures. Removes reasons not applicable per the code.
6300 Disenrollment from Managed Care Changes the section title, removes MCO denials and adds disenrollment information and a reference to the Uniform Managed Care Manual. Deletes Sections 6320, 6330, 6340, 6350, 6360 and 6370.
Appendix III LTSS Billing Matrix and Crosswalk Adds UC modifier for the CDS Option to Medically Dependent Children Program waiver services for minor home modifications and adaptive aids to Codes T2028, T2029, T2039 and S5165.
Form 2605, Form 2605-S and Instructions Member SK-SAI MDCP Review Signature Adds a new form and instructions per requirement of Senate Bill 1207.

20-2, Changes to Section 1614, Section 3200, Section 3327.1, Section 3410, Section 4300, Section 4400 and Section 5212

20-2, Changes to Section 1614, Section 3200, Section 3327.1, Section 3410, Section 4300, Section 4400 and Section 5212 acarreras Thu, 06/11/2020 - 13:55
Body

Revision Notice 20-2; Effective September 1, 2020

 

The following change(s) were made:

Revised Title Change
1614 When and What Information May Be Disclosed Adds a link to an online question and complaint form.
3200 Member Reassessment Adds a requirement to submit the Individual Service Plan (ISP) tracking tool to the LTC Portal upon reassessment.
3327.1 Process for Reviewing the Individual Service Plan Expiring Report Removes Program Support Unit (PSU) processes and updates managed care organization (MCO) requirements for how to retrieve and use the report.
3410 Transfer from One Managed Care Organization to Another Updates how members may request an MCO transfer. Adds headings throughout the section for clarity. Updates the requirements for both the gaining and losing MCO. Updates the time frames to provide information.
4300 Private Duty Nursing Updates the section to match MCO notice guidance. The MCO must follow the Texas Medicaid Provider Procedure Manual (TMPPM) guidance for private duty nursing. Removes all other language as the information is in the TMPPM. Moves Section 4330 to 4310 and deletes Sections 4311 and 4320.
4400 Prescribed Pediatric Extended Care Centers Updates references, citations and information to match TMPPM guidance. Changes the flow of information for reading and ease of use, adding Section 4411 and moving information previously in 4411 to 4412.
5212 Services Available in the CDS Option Changes the title of the section and adds information based on House Bill 4533 services available in the Medically Dependent Children Program (MDCP) Waiver under the Consumer Directed Services (CDS) Option.

HHSC Policy Updates

HHSC Policy Updates acarreras Fri, 04/13/2018 - 10:15
Body

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

Contact Us

Contact Us rarefyev Thu, 03/30/2017 - 09:58
Body

For questions about the STAR Kids Handbook, email: MCO_Handbooks@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us