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.