2100, Money Follows the Person | Texas Health and Human Services

Printer-friendly version

Revision 22-3; Effective Dec. 1, 2022

2110 Traditional Money Follows the Person

Revision 22-2; Effective September 1, 2022

The managed care organization (MCO) must participate in the Texas Promoting Independence (PI) Initiative, also known as Money Follows the Person (MFP). The goal of the PI Initiative is to help individuals who are aged or who have disabilities live in the most integrated setting possible. The PI Initiative is Texas' response to the U.S. Supreme Court ruling in Olmstead v. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when the:

state's treatment professionals determine the placement is appropriate;
affected persons do not oppose such treatment; and
placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state-supported disability services.

The placement process for children in STAR Kids is known as permanency planning, "a philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Texas Government Code §531.151.)

Permanency planning is coordinated by a permanency planner assigned to the nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) under contract with Texas Health and Human Services Commission (HHSC). For NFs, permanency planners are contracted with an external vendor. For ICF/IIDs, permanency planners are contracted with Local Intellectual and Developmental Disability Authorities (LIDDAs).

Additionally, the MCO must designate a point of contact to receive referrals for NF residents who may be able to return to the community through the use of the Medically Dependent Children Program (MDCP) or another 1915(c) Medicaid waiver program. To be eligible for this option, an individual must reside in an NF until the individual meets the eligibility criteria for entry into MDCP or the other 1915(c) waiver program. This will include the development and approval of a written plan of care for safely moving back into a community setting. If a member chooses to remain in the NF and meets NF level of care (LOC), as identified in the Minimum Data Set, the MCO must honor this choice.

A STAR Kids member who enters an NF (excluding Truman Smith) or an ICF/IID will remain enrolled in the STAR Kids MCO for the provision of any covered services, including those provided through the Comprehensive Care Program, not provided through the facility as part of the daily rate. Reference the STAR Kids Contract, Section 8.1.15, for further information.

The MCO must have a protocol for quickly assessing the needs of members who have or will soon be discharged from an NF or ICF/IID. The MCO must assure timely access to service coordination and arrange for medically necessary or functionally necessary personal care services (PCS) or nursing services immediately upon the member’s transition from an NF or ICF/IID to the community.

When a STAR Kids member enters an NF or an ICF/IID, the MCO must:

determine the member’s assigned permanency planner;
contact the member’s assigned permanency planner within seven days of the member’s facility admission;
collaborate with the member, the legally authorized representative (LAR), and the assigned permanency planner to develop a plan of care to transition the member back to the community;
contact and assess the member no less than every 90 days while the member remains in the facility. As part of the quarterly assessment process, the MCO must collaborate with HHSC's contracted permanency planner to work with the member and the member's LAR to review community-based options; and
work with the member, the LAR, and the assigned permanency planner in the development of a transition plan when a member is discharged from the facility.

The MCO must maintain documentation of the assessments completed as part of this initiative and make them available for state review at any time.

An individual without Medicaid, and not enrolled in STAR Kids, requesting MDCP services through the MFP option must remain in the NF for no less than 30 days to meet the HHSC eligibility criteria to qualify for Medicaid. An individual cannot leave the NF until MDCP eligibility is also determined. The MDCP eligibility process could potentially take longer than the 30 days as required for HHSC Medicaid eligibility criteria. Program Support Unit (PSU) staff and the MCO must follow established time frames for processing an application for MDCP. PSU staff will authorize MDCP when all eligibility criteria are met. The permanency planner will assist the individual throughout this process.

For an individual who cannot reside in an NF for 30 days because they meet the medically fragile criteria, the Medicaid for the Elderly and People with Disabilities (MEPD) specialist can establish Medicaid eligibility using a combination of residence in an NF and enrollment in the MDCP to meet the 30-day requirement. Reference 2120, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual.

2111 Non-STAR Kids Individual Residing in an NF

Revision 23-3; Effective July 21, 2023

For requests to transition into the community under traditional Money Follows the Person (MFP) for a non-STAR Kids member, the individual's Texas Health and Human Services Commission (HHSC)-contracted permanency planner is the designated party responsible for the process. The permanency planner will:

identify the holistic strengths, challenges, and needs of the individual and the individual's family or legally authorized representative (LAR) as part of the permanency planning process;
lead the development of the individual's permanency plan;
educate the individual and LAR on 1915(c) Medicaid waiver options, including the Medically Dependent Children Program (MDCP);
document the individual's choice of the 1915(c) Medicaid waiver program; and
educate the individual about STAR Kids, including providing information about managed care and the importance of choosing a managed care organization (MCO).

Once the individual selects a 1915(c) Medicaid waiver program, the permanency planner will contact the Interest List Management (ILM) Unit staff within two business days to notify HHSC of the individual's 1915(c) Medicaid waiver selection under MFP and update the address on file to that of the LAR, if needed.

If the individual or LAR chooses a 1915(c) Medicaid waiver program other than MDCP, ILM Unit staff will verify the individual is on the interest list for the waiver program selected and immediately release the individual from the interest list in the Community Services Interest List (CSIL) database, using the bypass code “Residing in a Nursing facility.” ILM Unit staff will forward the request to the selected 1915(c) Medicaid waiver program. The permanency planner will work with the individual, LAR, and selected 1915(c) Medicaid waiver program staff to ensure program eligibility, MCO selection, and transition to services in the community.

Prior to the individual's discharge from the NF, the individual's selected MCO service coordinator must perform the initial SK-SAI and establish the initial ISP to reflect both MDCP services and any other identified supports, such as nursing or personal care services (PCS). The MCO initiates contact with the individual or LAR to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization.

Within 15 business days from contact with the individual or LAR, the MCO service coordinator performs the SK-SAI, including the MDCP module (record SK-SAI items Q.6.a and Q.6.b as 1 (yes) to ensure processing for MN and RUG). The MCO service coordinator must submit the SK-SAI to TMHP), following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of the assessment’s completion.

Within one business day of completing Form 2604, STAR Kids Individual Service Plan (ISP) - Service Tracking Tool, the MCO service coordinator must:

submit Form 2604 electronically following the requirements in Appendix I;
complete Section B, Waiver Assessment Report, of Form H3676; and
upload Form H3676 and, as needed, Form H2067-MC, Managed Care Programs Communication, to MCOHub.

Within one business day of verifying the applicant meets all eligibility criteria, PSU staff will upload the initial Form H2065-D, Notification of Managed Care Program Services, to MCOHub in the MCO’s STAR Kids folder, following the instructions in , STAR Kids MCOHub Naming Conventions.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D.

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must upload on MCOHub within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial.

If the individual chooses to leave the NF before being determined eligible for MDCP, the MDCP case must be denied.

2112 STAR Kids Member Residing in an NF

Revision 23-3; Effective July 21, 2023

When a STAR Kids member is admitted to a facility, the managed care organization (MCO) service coordinator must do the following:

contact the contracted Texas Health and Human Services Commission (HHSC) permanency planner within seven days of the member's admission;
coordinate with the permanency planner and assist with any of the member's needs as part of the permanency planning process, if needed, including sharing the most recent STAR Kids Screening and Assessment Instrument (SK-SAI) tool and individual service plan (ISP);
perform a new SK-SAI tool for a significant change in status upon discharge, unless one is required sooner for the Medically Dependent Children Program (MDCP); and
update the member’s ISP to reflect changes in the SK-SAI tool, if applicable.

For requests to transition to the community under traditional Money Follows the Person (MFP) for a STAR Kids member, the member’s permanency planner is the designated party responsible for part of the process. The permanency planner will:

identify the holistic strengths, challenges, and needs of the member and family or legally authorized representative (LAR) as part of the permanency planning process;
lead the development of the member's permanency plan;
coordinate with the MCO service coordinator in updating the member's ISP, if applicable;
educate the member and LAR on 1915(c) Medicaid waiver options, including MDCP; and
document the member's choice of the 1915(c) Medicaid waiver program;

Within two business days of the referral from ILM Unit staff, PSU staff must upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub in the MCO's STAR Kids folder.

The MCO initiates contact with the member or LAR to begin the assessment process within 10 business days of receipt of Form H3676.

Within 15 business days from contact with the member or LAR, the MCO service coordinator performs the SK-SAI. The MCO service coordinator must submit the SK-SAI to TMHP following the requirements in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, within 72 hours of completion of the assessment.

Within five business days of the MCO service coordinator receiving confirmation that the member meets MN, the service coordinator, in conjunction with the permanency planner, member and LAR, must develop the ISP using Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and determine a discharge date from the NF. The MCO service coordinator must submit the electronic Form 2604 to TMHP following the requirements in Appendix I within one business day of completion.

As needed, PSU staff collaborate with involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document any delays.

2113 MDCP MFP Applications Pending Due to Delay in NF Discharge

Revision 23-3; Effective July 21, 2023

Program Support Unit (PSU) and managed care organization (MCO) staff must work with an individual who has community living arrangements pending, but are not finalized. If the individual has an estimated date of discharge from a nursing facility (NF) that goes beyond a four month period, PSU staff should keep the request for services open.

An individual who has not made living arrangements to return to the community, cannot decide when to return to the community, or has no viable plan or support system in the community should be denied the Medically Dependent Children Program (MDCP). PSU staff deny the request for services and will:

send Form H2065-D, Notification of Managed Care Program Services, to the individual within two business days after the end of the four calendar month pending period; and
upload Form H2065-D to MCOHub in the MCO's STAR Kids folder, following the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions.

2120 MFP Limited NF Stay Option for a Medically Fragile Individual

Revision 22-2; Effective September 1, 2022

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option but is too medically fragile to reside in an NF for an extended period. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap);
tracheostomy;
renal dialysis;
24-hour/day supplemental oxygen dependence;
total nutrition through enteral tube feeding;
total parenteral nutrition (TPN);
seizures requiring medical intervention (e.g., emergency medication administration, oxygen) during the seizure, every day for the past six months;
documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
congestive heart failure requiring hospitalization and routine medication within the past six months; or
hospice.

An individual determined to be medically fragile and who is approved for a limited NF stay must stay at least part of two consecutive days in the NF. Managed care organizations (MCOs) must comply with MFP limited NF stay policy for continuity of services by ensuring services are authorized within 24 hours of NF discharge; therefore, an applicant may not discharge from the NF on a Friday, Saturday, Sunday or any day preceding a state holiday. The MCO must explain that the individual must not proceed with the limited NF stay until authorized to do so by the MCO. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy.

2121 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 22-2; Effective September 1, 2022

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or their managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or their MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual's name to the interest list. This request will not be considered a release from the interest list, but instead as a referral of an individual interested in by-passing the interest list through the MFP limited NF stay option.

ILM Unit staff must explain the following to the individual requesting to by-pass the MDCP interest list:

STAR Kids program, if not enrolled;
an overview of MDCP services;
the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
required medical documentation must be within 12 months of the date the documentation is submitted to ILM Unit staff, from the individual’s clinical record at the physician’s office, hospital, or clinic (not from a patient portal); and
admission and discharge documentation from the NF will be required.

ILM Unit staff will send Form 2406 to the individual, parent, guardian or legally authorized representative (LAR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian or LAR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian or LAR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered.

2130 Physician Determination of Medical Fragility

Revision 22-2; Effective September 1, 2022

The Texas Health and Human Services Commission (HHSC) nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the documentation is sufficient and the individual meets the medically fragile criteria. If the documentation is not sufficient, the HHSC nurse will request Interest List Management (ILM) staff to contact the individual, parent, guardian or LAR to obtain needed documentation. If the HHSC nurse is unable to approve, the information is sent to the HHSC physician for review. The HHSC physician will respond by email within seven days to the HHSC nurse with their decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

2131 Individual Who is Approved for a Limited NF Stay

Revision 23-3; Effective July 21, 2023

A STAR Kids managed care organization (MCO) must be selected prior to the limited nursing facility (NF) stay. If an MCO is not selected prior to the limited NF stay, the applicant will not qualify for the limited NF stay option.

Within two business days of the MCO selection, orally or in writing, PSU staff complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to MCOHub in the MCO's STAR Kids folder.

2132 MCO Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 23-4; Effective Dec. 1, 2023

When an individual is approved for a limited nursing facility (NF) stay, Program Support Unit (PSU) staff upload Form H3676, Managed Care Pre-Enrollment Assessment Authorization, to MCOHub advising the managed care organization (MCO) of the individual’s decision to complete a limited NF stay. The MCO must contact the individual, parent, guardian or legally authorized representative (LAR) within 14 days from the date the MCO receives Form H3676 to start the assessment process.

At the contact, the MCO must inform the individual, parent, guardian or LAR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO must explain to the individual, parent, guardian or LAR that the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must advise the individual that they must not proceed with the limited NF stay until authorized to do so by the MCO.

The MCO has 60 days to complete and submit all required assessments and forms, detailed in 2030, Managed Care Organization Coordination. If the applicant is medical assistance only (MAO) and does not have a Medicaid identification (ID) number, the MCO must use “+” in the Medicaid ID field when uploading Form 2604 to the Long Term Care (LTC) Online Portal. Once the individual has discharged from the NF and MDCP services have been authorized for 30 days, a Medicaid ID number will be assigned to the individual in the Texas Integrated Eligibility Redesign System (TIERS). TIERS will automatically update the Texas Medicaid & Healthcare Partnership (TMHP) LTC Online Portal and replace the “+” with the individual’s Medicaid ID number.

PSU staff will upload Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO's STAR Kids folder to notify the MCO of the approval pending completion of the limited NF stay. The MCO must notify PSU staff within five business days of the planned NF discharge date by uploading Form H2067-MC to MCOHub, following the instructions in Appendix IX.

For applicants not receiving Medicaid, Medicaid will not be established until 30 days after the applicant completes the limited NF stay if MDCP is authorized.

The MCO must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR and PSU staff. The MCO must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with Money Follows the Person (MFP) limited NF stay policy for continuity of services. The MCO service coordinator must advise the applicant that:

The NF stay will not be accepted as meeting MFP limited NF stay policy if MDCP services cannot be authorized within 24 hours after the NF discharge date.
A delay in completing the NF stay will delay the applicant’s MDCP services.

The MCO must notify PSU at least one business day before the applicant’s NF stay, and must immediately move forward with the NF stay process.

Within 24 hours of the limited NF stay, the MCO must notify PSU staff that the limited NF stay occurred by:

documenting the admission and discharge dates on Form H2067-MC; and
uploading Form H2067-MC in MCOHub, following the instructions in Appendix IX, requesting PSU staff approve MDCP services.

The MDCP effective date will be the first of the month in which the MFP applicant discharged from the NF.

MCOs must monitor the TMHP LTC Online Portal for the status of the member's ISP and to retrieve Form H2065-D.

2133 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 23-3; Effective July 21, 2023

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request that the MEPD specialist delay certification.

If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application.

MCOs must monitor the TMHP LTC Online Portal for the status of the member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian or legally authorized representative (LAR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting Interest List Management (ILM) Unit staff, as described in 2121, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian or LAR requesting to reopen the Medicaid application. The MCO must upload the letter on MCOHub in the MCO’s STAR Kids folder.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by uploading Form H2067-MC in MCOHub, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian or LAR that a new Form H1200 must be completed.