Revision 22-2; Effective September 1, 2022
2010 Initial Requests for Medically Dependent Children Program
Revision 22-2; Effective September 1, 2022
An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list according to the date and time of the request, regardless of the program's enrollment status. Individuals are released from the interest list in the order of the request date. An individual or their legally authorized representative (LAR) may request that the individual be placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.
If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.
The individual's name may only be added to the MDCP interest list if the individual is younger than age 21 and resides in Texas.
2020 Individual Enrolled in STAR Health
Revision 22-2; Effective September 1, 2022
See the Uniform Managed Care Manual (UMCM) for STAR Health members. The medical consenter appointed by Texas Child Protective Services (CPS) is the only individual who can accept or decline to pursue Medically Dependent Children Program (MDCP) services on behalf of the individual.
A member disenrolling from the STAR Health program due to exiting conservatorship may be eligible to continue their MDCP services through a STAR Kids MCO of their choice. Additional information on MDCP STAR Health members is in the STAR Health MDCP Policy Section 16.2 of the UMCM.
2030 Managed Care Organization Coordination
Revision 23-3; Effective July 21, 2023
The STAR Kids managed care organization (MCO) has 30 days from receipt of the initial authorization by Program Support Unit (PSU) staff to begin the assessment process in Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and complete all assessments for an individual applying for the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation to PSU staff, for a total of 60 days following receipt of the initial notice from PSU staff. Within 60 days of the MCO receiving Form H3676, the MCO must:
- verify the individual meets all other eligibility criteria referenced in 1000, Overview and Eligibility;
- complete the STAR Kids Screening and Assessment Instrument (SK-SAI), including the MDCP module and submit to Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP;
- obtain the member’s or Legally Authorized Representative’s (LAR's) signature on Form 2605, Member SK-SAI MDCP Review Signature;
- If member refuses to sign, the MCO must document the refusal on the form;
- obtain the individual's physician's signature on Form 2601, Physician Certification;
- once the Medical Necessity (MN) is approved (and the SK-SAI is in the status of processed/complete), complete Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and place in the member's file;
- complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool,
- submit electronically to TMHP LTC Online Portal following the requirements in Appendix I; and
- complete Section B, Waiver Assessment Report, of Form H3676 and upload to MCOHub.
Completion of the above activities must not cause a delay in services. If the MCO does not perform the actions listed above within 60 days from the date PSU staff uploaded Form H3676, Section A, Referral/Assessment Authorization, the MCO must upload Form H2067-MC, Managed Care Programs Communication, to MCOHub to advise PSU staff of any reason(s) for the delay. PSU staff will notify Managed Care Compliance & Operations (MCCO) of the delay and the reason for the delay.
Note: Refer to 2200, MDCP Start of Care and MN Expiration, for more information on MN expiration.
The MCO must schedule and complete the SK-SAI, including the MDCP module, within 30 days of receiving Section A of Form H3676 from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP within 72 hours of completion. For the purposes of this MCO requirement, the SK-SAI is considered "complete" when the MCO has obtained the physician's signature on Form 2601, obtained the member’s or LAR’s signature, or documented the member’s or LAR’s refusal to sign Form 2605, retained Forms 2601 and 2605 in the individual's or member’s case file, and uploaded Form H3676, Section B, to MCOHub.
Form 2601 is required to be completed for all initial assessments and significant change in condition assessments. This form may be requested, but is not required, for annual reassessments where no significant change in condition has been identified. The MCO must notify the member or LAR of the Form 2601 requirement. The MCO must submit Form 2601 to the applicant's physician for review and signature upon receiving Section A of Form H3676 from PSU staff but must submit no later than three business days after conducting the SK-SAI. Upon receipt of signed Form 2601, the MCO must complete and upload Form H3676, Section B, to MCOHub informing PSU the SK-SAI has been completed.
If Form 2601 is not received by the MCO within five business days of the initial request to the applicant’s physician, the MCO must attempt and document at least one telephone contact per week to the applicant’s physician to obtain Form 2601. The MCO must make at least three telephone contact attempts over at least a three-week period to obtain Form 2601 before the MCO can request for PSU staff to deny the applicant. If the MCO needs additional time to make required telephone contacts to obtain Form 2601, the MCO must upload Form H2067-MC to MCOHub to advise PSU staff. If at least three telephone attempts over at least a three-week period have occurred and the MCO has not obtained Form 2601, the MCO must notify the member or LAR and offer them the opportunity to contact the physician directly to request the physician submit the form to the MCO.
If the above activities have been completed and the MCO has not received Form 2601, upload Form H3676, Section B, to MCOHub requesting PSU staff deny the applicant MDCP due to MCO inability to obtain a physician’s signature on Form 2601. The MCO must make best efforts to obtain Form 2601 from the member’s physician.
SK-SAI Review Signature
The MCO must allow the member or LAR the opportunity to review the information gathered in the SK-SAI at the time of the home visit. The MCO must document the member’s acknowledgement and feedback on Form 2605 at the time of the home visit. If the member or LAR refuse to sign Form 2605, the MCO must document the refusal on the form at the time of the home visit.
On Form 2605, the MCO must document any of the member’s or LAR’s comments about the information gathered in the SK-SAI, document the member’s or LAR’s request on how they want to receive a copy of the final SK-SAI that is submitted to TMHP, and the MCO service coordinator must sign to acknowledge completion of the form at the time of the home visit.
At the time of the home visit, the MCO must educate the member or LAR on the peer-to-peer review process and offer the opportunity to request a peer-to-peer review with a physician of the member’s or LAR’s choice if the assessment results in a denial. Note: If the result of the assessment is a denial, the MCO is required to follow the policy in 6250, Denial/Termination of Medical Necessity.
The MCO is required to complete Form 2605 for all initial assessments, reassessments and significant change in condition assessments.
The MCO must contact the member to affirm and document any changes made to the SK-SAI after the home visit. If the member or LAR has any additional comments at the time of this contact, the MCO must document that concern.
Authorization of MDCP Services
A determination of MN for MDCP must be based on information collected as part of the SK-SAI. The MN determination must be made by TMHP staff before an individual can be authorized for MDCP services.
TMHP staff process the SK-SAI for an individual to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of medical acuity level and nursing facility (NF) staffing intensity, and is used in 1915(c) Medicaid waiver programs to establish the service plan cost limit. The MDCP module of the SK-SAI is used to determine the RUG.
Once TMHP staff process an SK-SAI, the MCO will receive a substantive response file with a three-digit RUG value. The RUG is alphanumeric and may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A “BC1” code indicates the SK-SAI does not have all the information necessary for TMHP staff to accurately calculate a RUG for the individual or member. Code “BC1” is not a valid RUG value to determine MDCP eligibility.
The MCO must correct the information on the SK-SAI within 14 business days of submitting the assessment that resulted in a “BC1” code. After 14 business days, the MCO must inactivate the SK-SAI and submit a new SK-SAI in its place. Information about the process of transmitting, correcting and inactivating an SK-SAI is available in Appendix I.
As a part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit linked to the RUG value assigned. The MCO must not terminate MDCP services for any reason. Only HHSC can terminate member enrollment.
Information for MDCP members exceeding the cost limit can be found in 3324, Individual Service Plan Exceeding the Cost Limit for Medically Dependent Children Program Services. If a denial of services is required, the MCO must follow the denial procedure found in 6240, Denial/Termination as a Result of Exceeding the Cost Limit.
Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the member does not experience gaps in authorizations and that authorizations are consistent with information in the member’s ISP.
The MCO must also adopt a methodology to track each member's monthly MDCP-related expenditures and provide an update on those expenditures to the member or LAR no less than once per month.