Revision 22-3; Effective Sept. 9, 2022

An individual applicant or member must meet the following criteria to be eligible for the Medically Dependent Children Program (MDCP):

  • be birth through 20;
  • live in Texas;
  • have an approved medical necessity (MN) for a nursing facility (NF) level of care (LOC);
  • have a need for at least one MDCP service not being addressed by other existing services and supports;
  • not be enrolled in another waiver program;
  • live in an appropriate living situation;
  • have a STAR Kids individual service plan (SK-ISP) with services under the established cost limit; and
  • have full Medicaid eligibility.

Refer to Appendix XIX, Mutually Exclusive Services, to determine if two services may be received simultaneously by an individual, applicant or member.

1200.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 25-1; Effective May 16, 2025

An individual, applicant or member must meet the following criteria stated in Title 1 Texas Administrative Code (TAC) Section 353.1155 to be eligible for the Medically Dependent Children Program (MDCP):

  • be under 21 years old;
  • live in Texas;
  • meet the level of care criteria (LOC) for medical necessity (MN) for nursing facility (NF) care determined by the Texas Health and Human Services Commission (HHSC);
  • have an unmet need for support in the community that can be met through one or more MDCP services;
  • choose MDCP as an alternative to NF services, described in 42 Code of Federal Regulations (CFR) Section 441.302(d);
  • not be enrolled in one of the following Medicaid Home and Community Based Services (HCBS) waiver programs approved by the Centers for Medicaid & Medicare Services (CMS):
    • the Community Living Assistance and Support Services (CLASS) Program;
    • the Deaf Blind with Multiple Disabilities (DBMD) Program;
    • the Home and Community-based Services (HCS) Program;
    • the Texas Home Living (TxHmL) Program; or
    • the Youth Empowerment Services waiver;
  • live in:
  • be determined by HHSC to be financially eligible for Medicaid under Chapter 358 of this title relating to Medicaid Eligibility for the Elderly and People with Disabilities.

An applicant receiving NF Medicaid is approved for MDCP if the applicant:

  • requests services while living in a NF; and
  • meets the eligibility criteria listed above.

1210 Medical Necessity Determination

Revision 25-1; Effective May 16, 2025

A Medically Dependent Children Program (MDCP) applicant or member must have an approved medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) to meet MDCP eligibility criteria. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI). The SK-SAI has screening questions and modules that assess for medical, behavioral and functional services. The managed care organization (MCO) conducts the SK-SAI and submits it into the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP).

The MCO must complete all initial assessment activities within 60 days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, from Program Support Unit (PSU) staff. This includes conducting and submitting the initial SK-SAI in the TMHP LTCOP.

The MCO must conduct and submit the SK-SAI to the TMHP LTCOP annually, or when the member has a change in condition, after initial enrollment. The MCO must not submit a reassessment SK-SAI in the TMHP LTCOP ahead of 90 days before the expiration of the member’s current STAR Kids individual service plan (SK-ISP). The reassessment SK-SAI must be submitted at least 30 days before the member’s current SK-ISP expires.

The TMHP LTCOP automatically processes the SK-SAI, determines MN and calculates the applicant or member’s three-alphanumeric digit Resource Utilization Group (RUG) value. The RUG is a measure of NF staffing intensity and is used in 1915(c) Medicaid waiver programs to categorize needs for an applicant or member and establishes the SK-ISP cost limit. The Office of the Medical Director (OMD) staff must manually review the SK-SAI to determine if the applicant or member meets the required MN criteria if the SK-SAI fails automatic MN approval.

The MCO uses the SK-SAI to create and submit the applicant or member’s SK-ISP in the TMHP LTCOP. The SK-ISP lists the applicant or member’s services and preferences for care and is valid for a 12-month period.

The SK-ISP is submitted to the TMHP LTCOP at initial enrollment and reassessment. The MCO does not submit an SK-ISP in the TMHP LTCOP for a service change or a change in condition. The MCO maintains amended SK-ISPs resulting from a service change or a change in condition SK-SAI in the member file.

The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the cost limit for the RUG value. PSU staff do not calculate the SK-ISP cost limit. PSU staff must verify the applicant or member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than the Annual Cost Limit on the SK-ISP in the TMHP LTCOP.

The MCO must continue to provide MDCP services at the MCO’s expense if they do not properly establish a plan of care (POC) and the applicant or member’s SK-ISP cost exceeds the individual limit. The MCO may not terminate MDCP enrollment if an applicant or member’s SK-ISP exceeds the cost limit.

An SK-SAI with incomplete 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 the TMHP LTCOP to accurately calculate a RUG for the applicant 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. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP, if they fail to submit the correction within 14 business days.

The TMHP LTCOP will automatically create an MDCP Enrollment Form when the MCO submits a new SK-SAI for MDCP if there is no existing MDCP Enrollment Forms or all other MDCP Enrollment Forms are in an invalid, denied or terminated status. PSU staff must verify data populated in the MDCP Enrollment Form is correct, update incorrect information, populate blank fields and save the enrollment form for all applicable MDCP cases. PSU staff must consult their supervisor before trying to manually create an MDCP Enrollment Form. 

1210.1 Texas Administrative Code Medical Necessity Determination Requirements

Revision 25-1; Effective May 16, 2025

Medical necessity (MN) is the prerequisite to participate in the Medically Dependent Children Program (MDCP). An individual, applicant or member must meet the following criteria stated in Title 26 of the Texas Administrative Code at Section 554.2401 to meet the MN criteria for participation in MDCP. MN exists when an individual, applicant or member meets the conditions described below:

  • The person must demonstrate a medical condition that:
    • is serious enough that the person's needs exceed the routine care which may be given by an untrained person; and
    • requires licensed nurses' supervision, assessment, planning, and intervention that are only available in an institution.
  • The person must require medical or nursing services that:
    • are ordered by a physician;
    • are dependent upon the person's documented medical conditions;
    • require the skills of a registered or licensed vocational nurse;
    • are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and
    • are required on a regular basis.

1210.2 Medical Necessity Approval Time Frame for Initial Eligibility Determinations

Revision 25-1; Effective May 16, 2025

A medical necessity (MN) approval is valid for 120 days from the Texas Medicaid & Healthcare Partnership (TMHP) MN approval date for an initial applicant. The managed care organization (MCO) must complete another initial STAR Kids Screening and Assessment Instrument (SK-SAI) if the applicant is not enrolled in the Medicaid for Dependent Children Program (MDCP) within 120 days from the MN approval date. 

1220 Individual Cost Limit

Revision 25-1; Effective May 16, 2025

A Medically Dependent Children Program (MDCP) applicant or member’s STAR Kids individual service plan (SK-ISP) must fall within the applicant or member’s cost limit. The managed care organization (MCO) conducts a STAR Kids Screening and Assessment Instrument (SK-SAI) to assess the applicant or member. The MCO submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). The TMHP LTCOP automatically processes the SK-SAI and calculates the applicant or member’s Resource Utilization Group (RUG) value and determines if medical necessity (MN) is approved. The MCO uses the SK-SAI to create the applicant or member’s SK-ISP. The cost of the applicant or member’s MDCP services listed on the SK-ISP must be at or under the RUG value.

Program Support Unit (PSU) staff must not calculate the SK-ISP cost limit as it is automatically calculated in the TMHP LTCOP SK-ISP Annual Cost Limit field. PSU staff must verify the applicant or member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than then Annual Cost Limit in the TMHP LTCOP SK-ISP.

PSU staff must refer to 1 Texas Administrative Code (TAC) Section 353.1155, and the STAR Kids Handbook (SKH) for more information about the MDCP cost limit.

1230 Unmet Need for at Least One Medically Dependent Children Program Service

Revision 18-0; Effective September 4, 2018

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 the MDCP, a member must have an unmet need for, and therefore use, at least one MDCP service during the individual service plan (ISP) year. 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 disenrollment from the waiver. For members without Supplemental Security Income (SSI) (i.e., medical assistance only (MAO) members), disenrollment from the MDCP waiver may result in a loss of Medicaid eligibility.

Individuals certified for medical assistance only (MAO) Medicaid by the Health and Human Services Commission (HHSC) receiving Community First Choice (CFC) services through a §1915(c) Medicaid 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.

1240 Age

Revision 18-0; Effective September 4, 2018

To be eligible to participate in the Medically Dependent Children Program (MDCP), an applicant or member must be under age 21.

1250 Citizenship and Identity Verification

Revision 18-0; Effective September 4, 2018

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 the Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Verification of citizenship and identity for Medically Dependent Children Program (MDCP) eligibility purposes is a one-time activity conducted by Medicaid for the Elderly and People with Disabilities (MEPD), as documented in the MEPD Handbook, Chapter D-5000, Citizenship and Identity. Once verification of citizenship is established and documented by MEPD specialists, verification is no longer required even after a break in eligibility. Therefore, applicants who are active Medicaid, Medicare or Supplemental Security Income (SSI) recipients do not require citizenship verification since verification occurred upon entry of those programs.

1260 Living Arrangement and Texas Residency

Revision 25-1; Effective May 16, 2025

The applicant or member must be a Texas resident to be eligible for Medically Dependent Children Program (MDCP) services. These services are outlined in Title 1 Texas Administrative Code (TAC) Section 353.1155(b)(1)(B), Medically Dependent Children Program.

If the applicant is under 18, the applicant must not live in a foster home that includes more than four children unrelated to the applicant, outlined in Title 1 TAC Section 353.1155(b)(1)(G)(ii).

Managed care organization (MCO) service coordinators must confirm the applicant or member, if under 18, lives with a family member, such as a parent, guardian, grandparent or sibling, defined in the Glossary. The MCO service coordinator must review guardianship documentation or get a statement from the applicant, member, legally authorized representative (LAR) or family member about the relationship. The MCO service coordinator must maintain this documentation in the member’s case file.

1270 Financial Eligibility

Revision; 25-1 Effective May 16, 2025

Title 1 Texas Administrative Code (TAC) Section 353.1155 states that an individual must be determined by the Texas Health and Human Services Commission (HHSC) to be financially eligible for Medicaid for eligibility in the Medically Dependent Children Program (MDCP).

Program Support Unit (PSU) staff review the Texas Integrated Eligibility Redesign System (TIERS) to determine if a Medicaid financial eligibility determination is required.

PSU staff are not required to get Form H1200, Application for Assistance – Your Texas Benefits, for an individual with an active type of Medicaid assistance in TIERS. PSU staff must refer to Appendix XVI, Medicaid Program Actions, to determine if the individual’s type of assistance (TOA) requires PSU staff to fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist to determine Medicaid financial eligibility for MDCP.

PSU staff must get a completed Form H1200 if an individual is not already Medicaid eligible. PSU staff must fax the completed Form H1200 with Form H1746-A, to the MEPD specialist within two business days of receipt. The MEPD specialist has 45 days, or up to 90 days if it is necessary to get a disability determination, to complete the application process.

An individual without Medicaid must return a completed and signed Form H1200 within 30 days from the mail date of the application. PSU staff must mail Form 2606, Managed Care Enrollment Processing Delay, with the original unsigned Form H1200, to the individual or legally authorized representative (LAR),within two business days of receipt of an unsigned Form H1200.

1270.1 Individual with a Qualified Income Trust

Revision 25-1; Effective May 16, 2025

An individual or applicant with a qualified income trust (QIT) may be determined financially eligible for the Medically Dependent Children Program (MDCP) even though their income is more than the special institutional income limit for the program.

PSU staff must refer questions about QIT to Access and Accessibility Services (AES). This is done by faxing Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist.