An official State of Texas website.
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.