Revision 22-3; Effective Dec. 1, 2022

Managed care organizations must comply with the requirements for member notices of Adverse Benefit Determination described in federal and state law, in the Medicaid managed care contracts, including Uniform Managed Care Manual, Chapter 3.21.

Revision 23-3; Effective July 21, 2023

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

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 MCOHub per the conventions identified in Chapter 16.2 of the Uniform Managed Care Manual. 

MDCP may be denied or terminated by HHSC 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. 

PSU will:

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

6210 Denial/Termination Due to Death

Revision 23-3; Effective July 21, 2023

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

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

Services must be terminated by PSU staff once the member’s death is confirmed. 

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

6220 Denial/Termination Due to Residence in a Nursing Facility

Revision 23-3; Effective July 21, 2023

The process for members living 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 MCOHub 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, he or she would be directed to pursue Money Follows the Person (MFP) found in 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 will be denied by HHSC.

6230 Denial/Termination of Medicaid Financial Eligibility

Revision 22-3; Effective Dec. 1, 2022

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.

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

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) waiver serves 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 to determine 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 a denial because exceeding the cost limit will be a rare occurrence 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. The MCO does not make the denial decision. That decision is made by HHSC.

6250 Denial/Termination of Medical Necessity

Revision 22-3; Effective Dec. 1, 2022

Medically Dependent Children Program (MDCP) participation is denied by HHSC when an applicant or member fails to meet medical necessity (MN) criteria.

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 to: 
  • discuss the missing information during a peer-to-peer with the physician (see process below); 
  • obtain any available missing information from the physician during the peer-to-peer; and 
  • provide that information to TMHP. If the missing information is not available, the MCO must provide to TMHP the reasons the information is not available.
• 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 peer-to-peer review request;
    • 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 monitoring the MN 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 or LAR’s choice and the MCO medical director. 
    • If the member or LAR requests the peer-to-peer review:
      • verify the physician of the member or LAR’s choice,
      • contact the physician of the member or 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 monitoring the MN process outlined below.
    • If the member or LAR refuse the peer-to-peer review:
      • document the refusal in the member’s file; and
      • continue monitoring the MN process as outlined below. 

The peer-to-peer review should cover items on the STAR Kids Screening and Assessment Instrument (SK-SAI) related to MN. The MCO must ensure that the member’s or 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 must 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 by 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 more information, listed in the TMHP LTC Online Portal as “MN Denied,” the MCO must help the member to get any additional medical information pertinent to the member’s MN determination from their physician. The MCO must help through calling the member and physicians to get necessary documents for provision to TMHP within the 14 business day time frame for consideration. Program Support Unit (PSU) staff will electronically generate Form H2065-D, Notification of Managed Care Program Services, within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP. 

If Form H2065-D is not received by the MCO within the TMHP LTCOP within two business days of the date the MN status of “Overturn Doctor Review Expired” appears in the TMHP LTCOP, the MCO must notify Program Support Unit (PSU) staff of the need for Form H2065-D.

6260 Unable to Locate

Revision 22-3; Effective Dec. 1, 2022

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

Before notifying PSU that the member cannot be found, the managed care organization (MCO) must make at least three efforts to contact members by phone. The phone 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 phone, 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 that the member cannot be located can come from:

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

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

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

Revision 23-3; Effective July 21, 2023

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 MCOHub 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 23-3; Effective July 21, 2023

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 MCOHub 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.

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. Section 438.56. Refer to the HHSC Uniform Managed Care Manual, Chapter 11.5 (PDF), Medicaid Managed Care (MMC) Member Disenrollment Policy, for procedures to request the involuntary disenrollment of members.