1000, Overview and Eligibility

Revision 22-3; Effective Dec. 1, 2022

Texas Government Code Section 533.00253 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 affect an individual's Medicaid eligibility or impact access to Medicaid services and supports. STAR Kids does change the way in which services are delivered. Children and young adults, 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.

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

  • identification and addressing of needs, including physical health, behavioral health services, and LTSS with development of an individual service plan (ISP);
  • 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 annually. This is done by a service coordinator using the STAR Kids Screening and Assessment Instrument (SK-SAI ). Within the time frame listed in the STAR Kids Contract, if a member has a significant change in condition, the MCO must reassess the member, update their individual service plan (ISP), as applicable, and authorize medically or functionally necessary services. The MCO must also reassess the member, revise their ISP, as applicable, and authorize necessary services upon request of the member, LAR, or health home. 

In addition to traditional Medicaid services, STAR Kids MCOs are responsible for delivering other services to children enrolled in the Medically Dependent Children Program (MDCP). MDCP is a home and community-based services program authorized and operated concurrently by Sections 1915(c) and 1115 of the Social Security Act. 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 number of program slots is limited by legislative appropriations, so HHSC maintains an interest list for MDCP. A child, young adult, or LAR may ask their MCO about how to be placed on the MDCP interest list at any time.

1100, Legal Basis and Values

Revision 22-2; Effective September 1, 2022

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 22-2; Effective September 1, 2022

The Texas Health and Human Services Commission (HHSC) mission is to provide individualized and 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 22-3; Effective Dec. 1, 2022

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. This is 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 22-3; Effective Dec. 1, 2022

STAR Kids members must receive any medically necessary services through their managed care organization (MCO) per 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 (THSteps) Program;
  • oral evaluation and fluoride varnish in conjunction with THSteps 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;
  • 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 23-4; Effective Dec. 1, 2023

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):

  • Attendant care is hands-on medical and non-medical care specific to meet the needs of a person. It includes skilled medical care, to the extent permitted by state law, and housekeeping activities which are incidental to the performance of the client-based care. Attendant care services include: 
    • Day activity and health services (DAHS) which includes nursing and personal care services, therapy extension services, nutrition services, transportation services and other supportive services. DAHS is for members 18 through 20 years and is provided at an adult day center.
    • Personal care services (PCS) are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. 
      • PCS includes help 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. Members who meet an institutional level of care receive personal care services through Community First Choice Personal Assistance Services (CFC-PAS). See below for more information.
    • Prescribed pediatric extended care center (PPECC) is a facility that provides nonresidential basic services. These services include medical, nursing, psychosocial, therapeutic and developmental services to medically dependent or technologically-dependent members under 21 for up to 12 hours per day. Members who qualify for private duty nursing also qualify for PPECC services.
    • Private duty nursing (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. 

Community First Choice (CFC)

CFC services are available to all STAR Kids members who have an assessed need for LTSS, identified by the SK-SAI, and who meet an institutional level of care (LOC) for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), or an institution for mental disease.

Members enrolled in a Section 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, also called CFC-PAS assists with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks. Members who meet a CFC LOC must have PAS billed through CFC. Members may not be authorized for PCS and CFC-PAS at the same time. 
  • Habilitation, also called CFC habilitation or CFC-HAB, 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 or legally authorized representatives (LARs) on how to manage and dismiss their attendants.

Medically Dependent Children Program (MDCP) – Additional Services

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 a nursing facility (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 include:

  • Adaptive aids 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 where they live. Adaptive aids must only be authorized after exhausting all Medicaid state plan services and other third-party resources.
  • Employment assistance is 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 helps members manage funds related to the services delivered through the CDS option. 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, which 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 stay in the community.
  • Respite services are short-term direct care services needed because of a member's disability. They provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
  • Supported employment helps 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 where 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 help the resident move from the NF into the community to receive MDCP services.

1230 Service Delivery Options for Certain Long-Term Services and Supports

Revision 22-3; Effective Dec. 1, 2022

STAR Kids provides members with an array of services 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 the following three service delivery options for the delivery of certain long-term services and supports (LTSS):

  • Agency option
  • Service Responsibility Option (SRO)
  • Consumer Directed Services (CDS)

Members who choose the agency option select an MCO-contracted agency to deliver 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 one or more approved CDS services, the MCO coordinates delivery of non-member directed services. In the CDS option, the member or their LAR, with assistance from a financial management service agency (FMSA), ensures the necessary supplies are obtained to provide all authorized services. FMSA personnel may be employed directly by, or through personal service agreements or contracts with, the providers.

In the delivery of state plan LTSS, the SRO may only be used for attendant care. A provider agency chosen by the member or their LAR is the employer of record for the attendant and handles business details (for example, paying taxes and conducting payroll). The agency also orients attendants to agency policies and standards before sending them to the member’s home. The member or their 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.

State plan LTSS available through the CDS and SRO service delivery options are:

  • Community First Choice habilitation (CFC-HAB);
  • Community First Choice personal assistance services (CFC-PAS), referred to as CFC-PCS for children; and
  • Personal care services (PCS) (non-CFC).

STAR Kids members receiving Medically Dependent Children Program (MDCP) services may choose the CDS option for the following services:

  • employment assistance;
  • flexible family support services;
  • respite;
  • supported employment;
  • minor home modifications; and
  • adaptive aids.

STAR Kids members receiving MDCP services may choose the SRO option for the following services:

  • Employment assistance
  • Flexible family support services
  • Respite
  • Supported employment

Find more information about these service delivery options in 5000, Service Delivery Options.

1300, Service Coordination

Revision 22-3; Effective Dec. 1, 2022

All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators. They may also enter into an arrangement with a health home that offers service coordinators to give 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 or legally authorized representatives (LARs) request information about a referral to a nursing or other long-term care facility, the service coordinator must inform the member or their LAR about options available through home and community-based services (HCBS) programs and to facility-based options.

MCO service coordinators are responsible for assessing a member's needs, goals, and preferences with respect to delivery of services 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 at least once per year. During the assessment visit, the service coordinator, through a person-centered planning process, must:

  • complete the SK-SAI, including the MDCP module and Nursing Care Assessment Module (NCAM) as applicable;
  • 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;
  • help 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 or their LAR about their rights and responsibilities regarding acts that constitute Abuse or Neglect (Child Protective Services) and Abuse, Neglect or Exploitation (Adult Protective Services); and
  • review member rights and responsibilities and MCO processes for service authorization, appeals and complaints.

1310 Service Coordination Requirements

Revision 22-3; Effective Dec. 1, 2022

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, at least once per quarter. Visits must be spaced no less than two months or more than three months apart, from a named service coordinator annually, in addition to monthly telephonic contacts in months where no face-to-face visit occurred or in the same month as the face-to-face visit when an unmet need was identified. Variance in this schedule must be requested by a member or their legally authorized representative (LAR) and documented in Section IX: Service Coordinator Follow-up Schedule of Form 2603, STAR Kids individual service plan (ISP) - Narrative. MCOs must verify and document a member’s preference for service coordination contacts annually if they have requested fewer than the required contacts for their assigned service level. 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) dependent on the member’s needs as identified in the initial telephonic screening. 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 or LAR, and documented on the ISP. Visits must be as evenly spaced as possible during the year. As a best practice, visits should be spaced not fewer than four months or greater than six months apart. Level 2 service coordinators must be either an RN, NP or 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 less needs than Level 2 members. MCOs must provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make a minimum of three telephonic contacts. The required visit and contacts must be as evenly spaced as possible during the year. As a best practice the MCO should make contact once every quarter. Level 3 service coordinators must have at least 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 live 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 fee-for-service 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)  

If the service coordinator changes, the MCO must notify members within five business days of the name and phone number of the new service coordinator and must document the information on the ISP. 
MCOs must notify all members in writing of the: 

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

1311 Member Refusal to Participate in Service Coordination

Revision 23-3; Effective July 21, 2023

The managed care organization (MCO) must educate the member on the importance of the STAR Kids Screening and Assessment Instrument (SK-SAI) process, the member’s identified service coordination level, the required contacts for the member’s identified service coordination level, and the importance of service coordination. 

A member may refuse to participate or take part in the SK-SAI, and may request to reduce service coordination contact or refuse any service coordination contacts. 

Definition

Member refusal means a member’s or member’s legally authorized representative’s  (LAR’s) unwillingness to participate in an assessment, service planning process or other program-related processes.

Refusal of SK-SAI

A member may refuse to participate in the SK-SAI process. If the member or LAR  declines the SK-SAI process, the MCO must document this in the member’s case file. The MCO must also document the applicant or member was offered an in-person visit and was not experiencing any extraordinary circumstances. This documentation must be provided to HHSC by the MCO upon request. 

When an applicant or member refuses to participate in the SK-SAI process, the MCO must send the member or LAR written information on the possible impacts to their Medicaid eligibility and services in the STAR Kids Program including the inability to make a medical necessity (MN) determination for Medically Dependent Children Program (MDCP) waiver services that would prevent eligibility for the waiver. 

For a MDCP applicant or member who refuses to participate in the SK-SAI, the MCO must notify Program Support Unit (PSU) of the refusal, and attempts made to schedule the assessment, using MCOHub and Form H2067-MC, Managed Care Programs Communication.

Reduction of Service Coordination Contact

Service coordination levels and required contacts are outlined in 1300 above. and in the STAR Kids Contract Section 8.1.38.6. The MCO must provide the member or LAR with the information on the member’s designated service coordination level and the required contacts for that service coordination level, and the importance of service coordination in meeting the member’s health care needs. 

A member or LAR may request to have fewer service coordination contacts than required by the member’s service coordination level. The MCO must educate the member on the importance of these service coordination contacts and must document any contact reduction request on Form 2603, STAR Kids Individual Service Plan (ISP) Narrative Tool. 

A member’s or LAR’s request to reduce service coordination contact does not change the member’s assigned service coordination level as outlined in Section 1300 above. The MCO service coordinator is responsible for ensuring the member’s identified health care needs are being met. The MCO must document any actions taken including contact, referrals, service changes or other follow-up on Form 2603 in the member’s case file. 

Refusal of Service Coordination

A member or LAR may refuse all service coordination contacts required by the member’s service coordination level. The MCO must educate the member on the importance of these service coordination contacts and must document any refusal of contact on Form 2603. 

A member’s or LAR’s refusal of service coordination contact does not change the member’s assigned service coordination level as outlined in Section 1300 above. The MCO is responsible for ensuring the member’s identified health care needs are being met. The MCO must document any action taken including contact, referrals, service changes or other follow-up on Form 2603 in the member’s case file. 

Minimum Required Contact for STAR Kids Members

No later than four weeks following the ISP start date, the MCO service coordinator must follow up with the member or LAR, either face-to-face or by phone, to ensure that necessary services are in place. The MCO must document the follow up on Form 2603 in the member’s case file. This contact is in addition to the required service coordination contacts and must be completed by the MCO.

Minimum Required Contact for Community First Choice (CFC) and MDCP

The minimum utilization of an MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they receive CFC. As stated in 42 Code of Federal Regulations Section 441.510(d), all members that qualify for MAO Medicaid and receive CFC services must meet MDCP waiver requirements and must receive at least one MDCP waiver service per month. 

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

Revision 22-3; Effective Dec. 1, 2022

Members will receive only their acute care services and some state plan LTSS such as private duty nursing (PDN) through STAR Kids if they:

  • have intellectual and developmental disabilities (IDD); 
  • and receive most of their long-term services and supports (LTSS) through one of the programs listed below:
    • Community Living Assistance and Support Services (CLASS)
    • Deaf Blind with Multiple Disabilities (DBMD)
    • Home and Community-based Services (HCS)
    • Texas Home Living (TxHmL)
    • Community ICF/IID

A member with IDD that meets the above criteria has a named managed care organization (MCO) service coordinator. The number of required service coordination visits or phone calls and level of service coordination varies by acuity and the member’s or legally authorized representative’s (LAR’s) personal preference.

The MCO service coordinator is responsible for the coordination of the member’s acute care services and capitated LTSS. A member with IDD also has a person outside of the MCO who, with the member, develops and implements a separate fee-for-service service plan and monitors the delivery of home and community-based services. This person is referred to as the LTSS service coordinator or case manager. The LTSS service coordinator or case manager also cooperates with the MCO service coordinator for the provision of acute care services. The MCO service coordinator must respond to requests from the member's LTSS service coordinator or case manager. With the member’s approval, the member’s LTSS service coordinator or case manager should invite the member’s MCO service coordinator to the member’s fee-for-service service planning team meetings and other interdisciplinary team meetings. MCO service coordinator attendance at these meetings is not mandatory but is strongly recommended and participation may be in person or telephonically. 

1330 Service Coordination and the Youth Empowerment Services Program

Revision 22-3; Effective Dec. 1, 2022

Members who receive services through the Youth Empowerment Services (YES) program receive their acute care services and some long-term services and supports (LTSS) such as day activity and health services (DAHS), private duty nursing (PDN), and Community First Choice (CFC), only through STAR Kids. They continue to receive their waiver services through the YES program. Members served by the YES program have a named managed care organization (MCO) service coordinator and are 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 case manager. The member’s case manager should invite MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, unless the member objects. These meetings are not mandatory but are strongly recommended and participation may be either in person or by phone. The MCO service coordinator is responsible for the coordination of these member's acute care services and capitated LTSS. 

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

Revision 22-3; Effective Dec. 1, 2022

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 institutional stays in psychiatric facilities;
    • Note: Extended means three cumulative or consecutive years in the past five years  
  • severe mental illness (SMI) and frequent visits to the emergency department; or 
  • 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 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 Health and Human Services Commission. Find more information about HCBS-AMH here.  

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 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 before 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 or scheduled dates for phone 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 live in an institution and are also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the RM, by phone or in-person, during the member's stay. Planning meetings focus on coordination of services when discharged 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.

1400, Medically Dependent Children Program

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) is a home and community-based services (HCBS) waiver program authorized under Section 1915(c) of the Social Security Act. The state delivers MDCP Section1915(c) services through the STAR Kids managed care program authorized under the Section 1115 Texas Healthcare Transformation and Quality Improvement Program Demonstration. The exception is the children in state conservatorship who receive their MDCP Section 1915(c) services through the STAR Health managed care program. 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 22-3; Effective Dec. 1, 2022

The goal of the Medically Dependent Children Program (MDCP) is to support families caring for children and young adults 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, MDCP Eligibility

Revision 22-3; Effective Dec. 1, 2022

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. See 1 Texas Administrative Code, Section 353.1155 for more information. Once an individual's name comes to the top of the list, determination of eligibility begins as the individual applies for services.  

  • The term “individual” refers to a person who has been released from the interest list and has not yet applied for Medicaid benefits. 
  • The term “applicant” refers to a person who has applied for Medicaid benefits. 
  • The term “member” refers to a person who is currently in a Medicaid eligibility category included in the STAR Kids managed care program, and is enrolled with a MCO.

MDCP is provided by authority granted to the state of Texas to allow delivery of long-term services and supports (LTSS) that help members 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 criteria described in 1 Texas Administrative Code, Section 353.1155.

1510 Medical Necessity Determination

Revision 22-3; Effective Dec. 1, 2022

A Medically Dependent Children Program (MDCP) waiver individual, 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 and members. TMHP processes the SK-SAI to determine MN and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used in waiver programs to establish the service plan cost limit.

When TMHP processes an SK-SAI, a three-alphanumeric digit RUG value 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  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 or that returns any other errors that require correcting. 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 inactivation to the SK-SAI to TMHP.

1511 Medical Necessity Determination for Individuals Residing in Nursing Facilities

Revision 22-2; Effective September 1, 2022

During initial contact with the applicant or member, the service coordinator must explore the individual’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.

The managed care organization (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.

1512 Medical Necessity Determination for Individuals Not Residing in Nursing Facilities

Revision 22-2; Effective September 1, 2022

For individuals 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 individual.

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 22-2; Effective September 1, 2022

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 listed in the ISP must be equal to or below the applicant’s ISP cost limit. 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 22-3; Effective Dec. 1, 2022

In addition to requiring an individual meet a nursing facility level-of-care, 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 MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year and must receive monthly monitoring when MDCP services are furnished on a less than monthly basis. 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 termination from the waiver. For members without Supplemental Security Income (SSI) (i.e., members certified for medical assistance only (MAO) Medicaid), termination from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for 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) Section 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 22-2; Effective September 1, 2022

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 22-2; Effective September 1, 2022

Managed care organization (MCO) service coordinators must confirm that the individual, 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 individual, legally authorized representative (LAR), or family member regarding relation. The service coordinator must maintain this documentation in the member's case file.

1570 Financial Eligibility

Revision 22-2; Effective September 1, 2022

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 receiving the appropriate type of Medicaid. For individuals who do not receive SSI, Medicaid financial eligibility is determined by the Texas Health and Human Services Commission. Managed care organizations must abide by the eligibility determination.

1600, Disclosure of Information

Revision 22-2; Effective September 1, 2022

1610 Confidential Nature of a Case Record

Revision 22-2; Effective September 1, 2022

Information collected in determining initial or continuing eligibility is confidential. The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) may disclose general information about policies, procedures or other methods of determining eligibility, and any other information that is not about or does not specifically identify a member. A member or their legally authorized representative (LAR) 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 22-2; Effective September 1, 2022

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

1611.1 Telephone Contact

Revision 22-2; Effective September 1, 2022

Establish the identity of an individual who identifies themselves 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) 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 or LAR by asking for the individual to provide Form H1826, 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. Legislators and members of their staff must also provide HHSC with Form H1826.

1611.2 In-Person Contact

Revision 22-2; Effective September 1, 2022

Establish the identity of the individual who presents themselves as a member or legally authorized representative (LAR) 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 22-2; Effective September 1, 2022

It is only acceptable to disclose personally identifiable information (PII) or protected health information (PHI) to the applicant, member, legally authorized representative (LAR) or a third-party to whom the applicant, member or LAR 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 September 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 22-2; Effective September 1, 2022

To dispose of documents with member-specific information, managed care organizations (MCOs) must follow procedures contained in the STAR Kids Managed Care Contract.

1614 When and What Information May Be Disclosed

Revision 22-2; Effective September 1, 2022

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 or legally authorized representative (LAR) to obtain the information. The applicant, member or LAR authorizes the release of information by completing and signing:

  • Form H1826, 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 or LAR. Withhold protected health information (PHI) from the case record, such as names of persons who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
    • a statement specifically authorizing HHSC or the MCO to release the information;
    • the name of the person or agency to whom the information will be released;
    • the purpose of the release;
    • an expiration event that is related to the member, the purpose of the release or an expiration date of the release;
    • a statement about whether refusal to sign the release affects eligibility for delivery of services;
    • a statement describing the applicant's or member's right to revoke the authorization to release information;
    • the date the document is signed; and
    • the signature of the applicant, member or LAR.

Note: If the case information to be released includes individually identifiable health information, the document must also tell the applicant, member, or LAR 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 22-2; Effective September 1, 2022

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 or legally authorized representative (LAR) 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 22-2; Effective September 1, 2022

The member or legally authorized representative (LAR) 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 H1826, 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

Revision 22-2; Effective September 1, 2022

Only the member's legally authorized representative (LAR) 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.

Note: An LAR is not automatically designated as a responsible party.

1619.1 Adults and Emancipated Minors

Revision 22-2; Effective September 1, 2022

If the member is an adult or emancipated minor, including married minors, the member's LAR 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 22-3; Effective Dec. 1, 2022

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

  • the minor child can consent to medical treatment by themselves. 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 themselves when the:
    • minor is on active duty with the U.S. military;
    • minor is 16 years or older, lives separately from the parents and manages their 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 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 HHSC;
    • 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 22-2; Effective September 1, 2022

The LAR 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 22-2; Effective September 1, 2022

A member or legally authorized representative (LAR) 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 or LAR 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 or LAR 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 23-3; Effective July 21, 2023

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 their selected managed care organization (MCO). This makes it crucial that when documents containing member information are uploaded in the incorrect MCO folder in MCOHub, 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 22-2; Effective September 1, 2022

The Texas Health and Human Services Commission (HHSC) and the managed care organization (MCO) must accommodate an applicant’s, member's or legally authorized representative’s (LAR’s) reasonable requests to receive communications by alternative means or at alternate locations.

The applicant, member or LAR 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 22-2; Effective September 1, 2022

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

The Member Handbook must be provided to the member or legally authorized representative (LAR) 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: https://www.sos.state.tx.us/tac/index.shtml.

1800, Notifications

Revision 22-1; Effective September 1, 2022

1810 Program Support Unit Notification Requirements

Revision 23-3; Effective July 21, 2023

Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member or legally authorized representative (LAR) advising of actions taken regarding program eligibility and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member or LAR 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 or LAR. The language preference of the member must be considered.

The applicant, member or LAR 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 or LAR when services are denied or program eligibility is terminated. PSU staff must notify the applicant or LAR on Form H2065-D of the denial of application within two business days of the decision. See also Section 6000, Denials and Terminations.

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

1820 MCO Notification Requirements

Revision 22-2; Effective September 1, 2022

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