6200, Denial or Termination of Medically Dependent Children Program

Revision 25-1; Effective March 3, 2025

HHSC initiates program level denials when the member does not meet one or more Medically Dependent Children Program (MDCP) eligibility criteria.

The managed care organization (MCO) must:

monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for the MN denial notice; and
notify the Program Support Unit (PSU) of the reason for denial request by submitting Form H2067-MC, Managed Care Programs Communication, to MCOHub per the naming conventions identified in Appendix IX, STAR Kids MCOHub Naming Conventions.

MDCP may be denied or terminated by HHSC for the following reasons, which will be included on Form H2065-D, Notification of Managed Care Program Services:

residence in a nursing facility for more than 90 days;
member voluntary withdrawal;
Medicaid financial eligibility;
exceeding the cost limit;
medical necessity (MN);
inability to locate the member; or
inability to complete the assessment.

PSU will:

mail the member Form H2065-D; and
upload Form H2065-D to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions.

6210 Denial or Termination Due to Death

Revision 25-1 ; Effective March 3, 2025

Program Support Unit (PSU) staff posts Form H2067-MC, Managed Care Programs Communication, to MCOHub in the managed care organization’s (MCO’s) STAR Kids folder within two business days of verification of the death of a member. They follow the instructions in Appendix IX, STAR Kids MCOHub Naming Conventions when posting Form H2067-MC.

HHSC will terminate MDCP enrollment upon verification of the death of a member within two business days of notification of the death of a member.

MCOs must notify the member’s family of the family’s responsibility to communicate the member’s death to the Social Security Administration (SSA).

The adverse action notification period does not apply in this situation.

6220 Denial or Termination Due to Residence in a Nursing Facility

Revision 25-1; Effective March 3, 2025

The denial or termination process for members living in a nursing facility (NF) other than the Truman Smith NF* is as follows:

For members enrolled in STAR Kids, the enrollment remains open while a member lives in an NF.
- For members with Supplemental Security Income (SSI) or SSI-related Medicaid, the member remains enrolled in STAR Kids, but PSU must suspend the Medically Dependent Children Program (MDCP) services per 3326, Suspension of Medically Dependent Children Program Services.
- For members without SSI or SSI-related Medicaid, such as medical assistance only (MAO) members, the member remains enrolled in STAR Kids, but the MCO must suspend MDCP services, per Section 3326.
If a member enrolled in MDCP has lived in an NF for 90 days or more, the managed care organization (MCO) must notify Program Support Unit (PSU) staff within 14 days following the 90th day of residence.
- To notify PSU staff, the MCO posts Form H2067-MC, Managed Care Programs Communication, to MCOHub in the MCO's STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Once a denial is complete and if a member decides to discharge from the NF, the member is directed to pursue Money Follows the Person (MFP) found in 2100, Money Follows the Person.

*Members enrolled in STAR Kids who enter the Truman Smith NF are excluded from STAR Kids and will receive services through traditional Medicaid. STAR Kids and MDCP eligibility will be denied by HHSC.

6230 Denial or Termination of Medicaid Financial Eligibility

Revision 22-3; Effective Dec. 1, 2022

A member's continued receipt of STAR Kids services is dependent on financial eligibility determined by Supplemental Security Income (SSI) or medical assistance only (MAO) program requirements.

The member is notified of denial of financial eligibility by either Social Security Administration (SSA) staff for SSI or Medicaid for the Elderly and People with Disabilities (MEPD) specialists for MAO. The individual may appeal the financial denial using SSA or MEPD processes, as appropriate.

Notification can come from:

monthly reports;
Enrollment Resolution Services (ERS);
an MCO; or
other reliable sources.

The chart below describes how to proceed if financial eligibility is denied.

When the individual is denied SSI:	When the individual is denied MAO:
Disenrollment from the STAR Kids program occurs effective the last date of Medicaid eligibility. This is usually the last day of the current or following month. The individual has the right to appeal. The individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long-term services and supports (LTSS). For example, Community Attendant Services, Family Care, Title XX programs or state-funded programs. Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established per the date of the request.	Disenrollment from the STAR Kids program occurs effective the last date of Medicaid eligibility. This is usually the last day of the current or following month. The individual has the right to request a State Fair Hearing. The individual can contact the local HHSC office to request other LTSS. For example, Community Attendant Services, Family Care, Title XX programs or state-funded programs. Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established per the date of the request.

When the individual is denied SSI:

When the individual is denied MAO:

Disenrollment from the STAR Kids program occurs effective the last date of Medicaid eligibility. This is usually the last day of the current or following month.
The individual has the right to appeal.
The individual can contact the local Texas Health and Human Services Commission (HHSC) office to request other long-term services and supports (LTSS). For example, Community Attendant Services, Family Care, Title XX programs or state-funded programs.
Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established per the date of the request.

Disenrollment from the STAR Kids program occurs effective the last date of Medicaid eligibility. This is usually the last day of the current or following month.
The individual has the right to request a State Fair Hearing.
The individual can contact the local HHSC office to request other LTSS. For example, Community Attendant Services, Family Care, Title XX programs or state-funded programs.
Depending on the availability of local services, the individual may be placed on the interest list if Medicaid eligibility cannot be established per the date of the request.

6240 Denial or Termination as a Result of Exceeding the Cost Limit

Revision 25-1; Effective March 3, 2025

The Medically Dependent Children Program (MDCP) waiver serves individuals who can continue to live in their own home, family home or agency foster home if the supports of their informal networks are augmented with basic services and supports through the waiver. The managed care organization (MCO) must consider all available support systems to determine if the MDCP individual service plan (ISP) ensures the needs of the applicant or member.

As part of the individual service planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit or resource utilization group (RUG) value assigned by Texas Medicaid Healthcare Partnership in the Medicaid Management Information System. Because MDCP members primarily receive state plan services, it is expected that exceeding the cost limit for members will be a rare occurrence.

When MDCP applicants or members exceed their assigned cost limit, the MCO must notify Program Support Unit staff of the MDCP program denial request of MDCP and maintain appropriate documentation to support the denial. The MCO's documentation of this type of denial request is based on the inadequacy of the ISP, including both MDCP and non-MDCP services, to meet the needs of the individual within the RUG cost limit. The MCO does not make the denial decision. That decision is made by HHSC.

6250 Denial or Termination of Medical Necessity

Revision 25-2; Effective March 1, 2025

Medically Dependent Children Program (MDCP) participation is denied by HHSC when an applicant or member fails to meet medical necessity (MN) criteria.

The managed care organization (MCO) must monitor the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal for notification of a preliminary denial of medical necessity MN Pending Denial.

When the MN is in the MN Pending Denial status, the MCO must:

Verify with the HHSC nurse assessor what information is missing for MN to:
- discuss the missing information during a peer-to-peer with the physician listed in the process below;
- get any available missing information from the physician during the peer-to-peer; and
- provide that information to HHSC;
- the MCO must provide the reasons the information is not available to HHSC, if the missing information is not available.
Review Form 2605, Member STAR Kids Screening and Assessment Instrument (SK-SAI) MDCP Review Signature, Question 8.
- If the answer on Form 2605 is marked Yes:
  - contact the member or legally authorized representative (LAR) to confirm the peer-to-peer review request;
  - contact the listed physician of choice on Form 2605 to schedule and complete a peer-to-peer review;
  - submit any information obtained during the review to TMHP by fax for HHSC use to support MN; and
  - continue monitoring the MN process as outlined below.
- If the answer on Form 2605 is marked No:
  - Contact the member or LAR and offer an opportunity to hold a peer-to-peer review with the treating physician of the member or LAR’s choice and the MCO medical director.
  - If the member or LAR requests the peer-to-peer review:
    - verify the physician of the member or LAR’s choice;
    - contact the physician of the member or LAR’s choice to schedule and complete a peer-to-peer review;
    - submit any information obtained during the review to TMHP by fax for HHSC use to support MN; and
    - continue monitoring the MN process outlined below.
  - If the member or LAR refuse the peer-to-peer review:
    - document the refusal in the member’s file; and
    - continue monitoring the MN process as outlined below.

The peer-to-peer review should cover items on the SK-SAI related to MN. The MCO must ensure that the member’s or LAR’s physician of choice has access to the completed SK-SAI before the peer-to-peer review.

Any information obtained in the peer-to-peer review must be submitted to TMHP by fax for HHSC use.

The MCO must ensure that the peer-to-peer review does not affect member rights to appeal an initial assessment or reassessment through the MCO internal appeal process or the state fair hearing process.

In addition, the MCO must monitor the TMHP LTC Online Portal through the final MN determination.

The MN status of MN Denied in the TMHP LTC Online Portal is the period when the MDCP waiver applicant's or member's physician has 14 business days to submit more information. Once an SK-SAI MN status is in MN Denied status, several actions may follow:

MN Approved: The status changes to MN Approved if the HHSC doctor overturns the denial because more information is received;
Overturn Doctor Review Expired: The status changes to Overturn Doctor Review Expired when the 14-business day period for the HHSC doctor to overturn the denied MN has expired. No more information was submitted for the doctor review. The denied MN remains in this status unless a fair hearing is requested; or
Doctor Overturn Denied: The status changes to Doctor Overturn Denied when more information is received but the HHSC doctor does not believe the information submitted is sufficient to approve an MN. The denied MN remains in this status unless a fair hearing is requested.

While the MN is in the MN Denied status, the MCOs must monitor the TMHP LTC Online Portal for the MN status by completing a current activity or Form Status query in the TMHP LTC Online Portal at least every seven days. If a member’s MN status enters the period when the MDCP waiver applicant or member’s physician has 14 business days to submit more information, listed in the TMHP LTC Online Portal as MN Denied, the MCO must help the member get any additional medical information pertinent to the member’s MN determination from their physician. The MCO must help by calling the member and physician(s) to get necessary documentation and submit to TMHP in 14 business days to be considered by HHSC staff. Program Support Unit (PSU) staff electronically generate Form H2065-D, Notification of Managed Care Program Services, within two business days of the date the MN status of Overturn Doctor Review Expired appears in the TMHP LTC Online Portal.

If Form H2065-D is not received by the MCO in the TMHP LTC Online Portal within two business days of the date the MN status of Overturn Doctor Review Expired appears in the TMHP LTC Online Portal, the MCO must notify Program Support Unit (PSU) staff of the need for Form H2065-D.

6260 Unable to Locate

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) must be denied when Program Support Unit (PSU) staff are notified that a member cannot be found.

Before notifying PSU that the member cannot be found, the managed care organization (MCO) must make at least three efforts to contact members by phone. The phone contact attempts must be made on separate days, over a period of no more than five business days and must be made at a different time of day upon each attempt.

If an MCO is unable to reach a member or a member’s legally authorized representative (LAR) by phone, the MCO must mail written correspondence to the member and member’s LAR explaining the need to contact the MCO and requesting that the member or member’s LAR contact the MCO as soon as possible.

If the MCO has not made any contact with the member or LAR 15 business days after sending the written correspondence, the MCO must attempt to contact the member or LAR in person by visiting the member’s address on file.

Notification that the member cannot be located can come from:

monthly reports;
Managed Care Compliance Operations (MCCO);
an MCO; or
other reliable sources.

If the MCO is still unable to locate the member and wishes to request a denial or termination, the MCO must include all documented attempts when sending notification to PSU staff.

6270 Denial or Termination Due to Failure to Meet Other Program Requirements

Revision 23-3; Effective July 21, 2023

Use this denial citation if the applicant or member does not meet a Medically Dependent Children Program (MDCP) requirement mentioned in Sections 6210 through Section 6260 above. For example, this citation would be used if the applicant or member does not require at least one service. Within two business days of the denial, Program Support Unit (PSU) staff must:

send the applicant or member Form H2065-D , Notification of Managed Care Program Services; and
post Form H2065-D to MCOHub in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX , Naming Conventions.

6280 Denial or Termination for Other Reasons

Revision 23-3; Effective July 21, 2023

Use this citation if initiating denial or termination for a reason not covered in Sections 6210 through Section 6270. Within two business days of the denial, Program Support Unit (PSU) staff must:

send the member Form H2065-D , Notification of Managed Care Program Services; and
post Form H2065-D to MCOHub in the managed care organization's (MCO's) STAR Kids folder, following the instructions in Appendix IX , Naming Conventions.

Notification can come from:

monthly reports;
Enrollment Resolution Services (ERS);
an MCO; or
other reliable sources.