Revision 23-4; Effective Dec. 1, 2023

All STAR Kids members are reassessed at least annually using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days before the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid program eligibility. If there is a delay in activities, the MCO must upload Form H2067-MC, Managed Care Programs Communication, to MCOHub, in their designated STAR Kids folder, documenting the reason for delay.

Before the end date of the annual SK-SAI, including applicable modules, the MCO must initiate an annual reassessment to determine and validate continued need for services for each member. The MCO must not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the member's previous assessment using the SK-SAI. 

For members in MDCP, reassessment must occur no later than 30 days before the end date of the current ISP on file. This includes posting Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool to the Long-Term Care (LTC) Online Portal. As part of the assessment and reassessment, the MCO must inform the member about Consumer Directed Services and Service Responsibility options as described in 5200, Consumer Directed Services. The MCO is expected to complete the same activities for each annual reassessment as required for the initial eligibility determination.

The reassessment SK-SAI will have required pre-populated information gathered during the previous assessment. The MCO must confirm the accuracy of pre-populated information with the member or member’s legally authorized representative (LAR) and make any necessary adjustments. The MCO must not administer the pre-populated SK-SAI without previously completing the full SK-SAI.

For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member or the member’s LAR.

3210 Reassessment of Medical Necessity or Level of Care

Revision 23-3; Effective July 21, 2023

For members requiring a reassessment of medical necessity (MN) for a nursing facility (NF) level of care (LOC) for continued eligibility for Community First Choice (CFC) or Medically Dependent Children Program (MDCP) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI). This includes appropriate modules, no earlier than 90 days before or no later than 30 days before the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Q6a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment and there has been no change to the member's health status. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization or program eligibility.

For members receiving CFC services with an LOC for an institution of mental disease (IMD) or intermediate care facility serving individuals with an intellectual disability or related condition (ICF/IID), the MCO must reach out to the Local Mental Health Authority (LMHA) or Local Intellectual or Developmental Disability Authority (LIDDA). This ensures a reassessment is scheduled before the expiration of the member’s LOC assessment. The MCO must work with the LMHA assessing for IMD LOC, or the LIDDA, assessing for an ICF/IID LOC.

If the reassessment ISP is developed but not submitted due to the member's timely appeal of an MDCP denial, the individual's services continues using the existing ISP until a decision is received from the hearing officer. Once the fair hearing decision is reached, PSU staff and the MCO coordinate the submission of a reassessment ISP to ensure ISP records are correct and the reassessment ISP processes correctly.

If a member is reassessed and MN is denied, within five business days of the initial MN denial date on the TMHP Long-Term Care (LTC) Online Portal, the MCO must notify PSU staff by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub, asking PSU staff to generate Form H2065-D, Notification of Managed Care Program Services. This form is generated in the LTC Online Portal at reassessment. See 3328, Reassessment Notification Requirements, for more information.