1400, Service Coordination through the Managed Care Organization

Revision 18-0; Effective September 4, 2018

All STAR Kids members have access to service coordination from their managed care organization (MCO). The MCO may employ service coordinators, but may also enter into an arrangement with an integrated health home that offers service coordinators to provide some service coordination functions through the member’s health home. To integrate the member’s care while remaining informed of the member’s needs and condition, the MCO service coordinator must actively involve the member’s primary and specialty care providers, including behavioral health service providers, and providers of non-capitated services and non-covered services. When members, legally authorized representatives (LARs) or authorized representatives (ARs) request information regarding a referral to a nursing facility (NF) or other long-term care facility, the MCO service coordinator must inform the member, LAR or AR about options available through home and community based services programs, in addition to facility-based options.

MCO service coordinators are responsible for assessing a member’s needs using the STAR Kids Screening and Assessment Instrument (SK-SAI), developing an individual service plan (ISP) for every member, and authorizing services identified on the ISP. During the annual face-to-face visit, the MCO service coordinator must:

  • review the member’s current short-term and long-term goals and objectives, as documented in the ISP;
  • acknowledge and document goals and objectives the member has achieved or with which the member has made progress;
  • acknowledge and document goals and objectives that may need to be adjusted;
  • develop new goals and objectives with input from the member, family, LAR, AR and providers;
  • update the member’s ISP;
  • assist with development and management of the ISP and budget for members receiving Medically Dependent Children Program (MDCP) services;
  • inform members receiving long term services and supports (LTSS) about the Consumer Directed Services (CDS) and Service Responsibility Option (SRO);
  • educate the member, LAR or AR about their rights regarding acts that constitute abuse or neglect (Child Protective Services) and abuse, neglect or exploitation (Adult Protective Services (APS)); and
  • review member rights and MCO processes for service authorization, appeals and complaints.

1410 Service Coordination Requirements

Revision 18-0; Effective September 4, 2018

Managed care organizations (MCOs) provide a different level of service coordination, depending on a member’s needs. Members with more complex needs receive more service coordination than members whose needs are less complex.

Members with the highest needs are designated as Level 1 members in the STAR Kids Managed Care Contract. These members receive a minimum of four face-to-face visits from a named MCO service coordinator annually, in addition to monthly telephone calls, unless otherwise requested by a member, legally authorized representative (LAR) or authorized representative (AR). Level 1 MCO service coordinators must be a registered nurse (RN), nurse practitioner (NP), physician’s assistant (PA), social worker (MSW, LCSW or LBSW), or licensed professional counselor (LPC) if the member’s service needs are primarily behavioral. Level 1 members include those who:

  • are enrolled in the Medically Dependent Children Program (MDCP) or Youth Empowerment Services (YES) waiver program;
  • have complex needs or a history of developmental or behavioral health issues (multiple outpatient visits, hospitalization or institutionalization within the past year);
  • are diagnosed with severe emotional disturbance (SED) or serious and persistent mental illness (SPMI); or
  • are at risk for institutionalization.

Level 2 members have specialized needs that are less complex than Level 1 members. Level 2 members receive a minimum of two face-to-face visits and six telephonic contacts annually from a named MCO service coordinator, unless otherwise requested by the member, LAR or AR. Level 2 MCO service coordinators must be either an RN, NP, PA, have an undergraduate or graduate degree in social work or a related field, or be a licensed vocational nurse (LVN) with previous service coordination or case management experience. Level 2 members include members who:

  • do not meet the requirements for Level 1 but receive long term services and supports (LTSS);
  • the MCO believes would benefit from a higher level of service coordination based on results from the STAR Kids Screening and Assessment Instrument (SK-SAI) and additional MCO findings;
  • have a history of substance abuse (multiple outpatient visits, hospitalization or institutionalization within the past year); or
  • are without SED or SPMI, but who have another behavioral health condition that significantly impairs function.

Level 3 members have fewer needs than Level 2 members. MCOs are required to provide Level 3 members with one face-to-face visit, in which the SK-SAI is completed, and make three telephonic contacts annually, at minimum. Level 3 MCO service coordinators must have a minimum of a high school diploma or a general education diploma (GED) and direct experience working with children and young adults with similar conditions or behaviors in three of the last five years.

Members receiving Level 1 or Level 2 service coordination must have a single named person as their assigned MCO service coordinator. Level 3 members, LARs or ARs may request a single named MCO service coordinator by calling the service coordination hotline on the back of their STAR Kids member ID card. In addition, the MCO must provide a named service coordinator for members who qualify for Level 3 who reside in a nursing facility (NF) or community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or who are served by one of the following non-capitated §1915(c) Medicaid waiver programs: Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS) or Texas Home Living (TxHmL). The MCO must notify members within five business days of the name and telephone number of the new MCO service coordinator, if the service coordinator changes.

MCOs must notify all members in writing of the:

  • name of the service coordinator;
  • telephone number of the service coordinator;
  • minimum number of contacts he or she will receive every year; and
  • types of contacts he or she will receive.

1420 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

1430 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

1440 Reserved for Future Use

Revision 23-3; Effective May 22, 2023

 

1441 Program Point of Contact

Revision 18-0; Effective September 4, 2018

Each managed care organization (MCO) must have a designated program point of contact (PPOC) for the Home and Community Based Services - Adult Mental Health (HCBS-AMH) program. The PPOC is responsible for:

  • ensuring MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
  • responding within three business days to concerns from the Texas Health and Human Services Commission (HHSC) or recovery managers (RMs) to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the HCBS-AMH program.

1442 Managed Care Organization Service Coordination Responsibility

Revision 18-0; Effective September 4, 2018

Managed care organization (MCO) service coordinators must participate in telephonic recovery plan meetings, as scheduled by Texas Health and Human Services (HHSC) or recovery managers (RMs), and provide any requested member-specific information prior to the meeting. MCO service coordinators must:

  • Send requested information to the RM or HHSC three business days prior to the scheduled recovery plan meeting. This information includes:
    • updating the member’s condition;
    • sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
    • upcoming MCO service coordinator face-to-face appointments and/or scheduled dates for telephonic contacts with the member; and
    • relevant member treatment documents as requested by the RM or HHSC.
  • Respond to ad-hoc requests from the RM or HHSC with "Urgent" in the subject line within one business day.
  • Respond to non-urgent ad-hoc requests in a timely manner.
  • Coordinate with HHSC and the RM when a member transitions into or out of HCBS-AMH.

HCBS-AMH may provide transitional planning for members who reside in an institution and also enrolled in a STAR Kids MCO. MCO service coordinators must participate in planning meetings with the RM, telephonically or in-person, during the member’s stay. Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution. MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR Kids MCOs must follow all discharge planning requirements, as outlined in the STAR Kids Managed Care Contract, Section 8.1.38.10.