2001 Medically Dependent Children Program Eligibility

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.

2001.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 22-3; Effective Sept. 9, 2022 

An individual, applicant or member must meet the following criteria as 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; 
  • reside in Texas; 
  • meet the level of care criteria (LOC) for medical necessity (MN) for nursing facility (NF) care as 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, as 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 will be approved for MDCP if the applicant:

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

2002 Medical Necessity Determination

Revision 24-3; Effective Aug. 26, 2024

A Medically Dependent Children Program (MDCP) applicant 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 managed care organization (MCO) conducts and submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). An MDCP Enrollment Form will automatically be created in the TMHP LTCOP when the MCO submits an initial SK-SAI. 

The MCO uses the SK-SAI to create the applicant’s STAR Kids individual service plan (SK-ISP). The SK-ISP lists the applicant’s services and preferences for care. The cost of the applicant’s MDCP services listed on the SK-ISP must be at or under the Resource Utilization Group (RUG) value.

Program Support Unit (PSU) staff do not calculate the SK-ISP cost limit. The TMHP LTCOP automatically calculates the cost limit based on the RUG value. 

2002.1 Texas Administrative Code Medical Necessity Determination Requirements

Revision 22-3; Effective Sept. 9, 2022 

Medical necessity (MN) is the prerequisite for participation in the Medically Dependent Children Program (MDCP). MN exists when an individual, applicant or member meets the conditions described below:

  • The individual must demonstrate a medical condition that: 
    • is of sufficient seriousness that the individual’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 available only in an institution. 
  • The individual must require medical or nursing services that: 
    • are ordered by a physician; 
    • are dependent upon the individual’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.

2002.2 Medical Necessity Approval Time Frame for Initial Eligibility Determinations

Revision 23-4; Effective Aug. 21, 2023 

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 a new 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.

Program Support unit (PSU) staff must complete the following activities within two business days from the MN expiration of 120 days:

  • upload Form H2067-MC,  Managed Care Programs Communication, to TxMedCentral advising the MCO:
    • the approved MN determination is past 120 days; and
    • a new initial SK-SAI is required for PSU staff to determine MDCP eligibility;
  • upload Form H2067-MC to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record; and
  • document the HEART case record.

The MCO must submit a new initial SK-SAI to the TMHP Long Term Care Online Portal (LTCOP) before PSU staff can determine MDCP eligibility. 
 

2010 Initial Requests for Medically Dependent Children Program

Revision 18-0; Effective September 4, 2018

An individual requesting services through the Medically Dependent Children Program (MDCP) must be placed on the MDCP interest list, regardless of the program’s enrollment status, according to the date and time of the request. Individuals are released from the MDCP interest list in the order of their request date. An individual is placed on the MDCP interest list by calling Interest List Management (ILM) Unit staff’s toll-free number at 877-438-5658.

If a Texas Health and Human Services Commission (HHSC) regional office or managed care organization (MCO) service coordinator receives a request for MDCP services, they inform the individual about the interest list and refer the individual directly to ILM Unit staff at 877-438-5658 for placement on the interest list.

The individual’s name may only be added to the MDCP interest list if the individual is less than age 21 and resides in Texas.

2020 Interest List Management Unit Responsibilities

Revision 24-3; Effective Aug. 26, 2024

The Interest List Management (ILM) Unit are Texas Health and Human Services Commission (HHSC) staff responsible for maintaining and releasing individuals from the Medically Dependent Children Program (MDCP) interest list (IL). ILM Unit staff must use the Community Services Interest List (CSIL) database to track Texas residents who request MDCP services. ILM Unit staff must release individuals from the MDCP IL as slots become available.

ILM Unit staff perform the following activities for individuals who request MDCP services:

  • place individuals on the MDCP IL in chronological order;
  • maintain annual contact requirements;
  • release individuals from the MDCP IL when funding is available; and
  • confirm individuals on the MDCP IL are viable MDCP candidates before release by:
    • verifying all contact information is correct;
    • checking the Texas Integrated Eligibility Redesign System (TIERS) to determine the Medicaid eligibility status; and
    • confirming the individual is still interested in MDCP services.

ILM Unit staff must complete annual contacts for individuals on the MDCP IL to verify the current address and phone number and confirm continued interest in the program. The interest list status automatically updates to an inactive status if no response is received from the individual within 120 days of the annual contact. The individual remains in an inactive status until the individual notifies ILM Unit staff of continued interest in MDCP.

Program Support Unit (PSU) staff must refer the individual to the ILM Unit at 877-438-5658 to add the individual to the MDCP IL for the first time.

Once an individual’s released from the MDCP IL, ILM Unit staff perform the following:

  • verify the individual’s Medicaid type of assistance (TOA) in TIERS, if applicable;
  • contact the individual by phone to notify them they reached the top of the interest list;
  • confirm continued interest in MDCP;
  • provide a general description of MDCP services;
  • encourage the individual to contact the MCO for more information and available services, if applicable;
  • create a PSU MDCP interest list release (ILR) case record assignment in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • assign each MDCP ILR HEART case record to PSU staff for individuals who confirm interest in MDCP; and
  • update the CSIL database record’s status to assigned.

If the individual does not wish to pursue MDCP:

  • the individual can be added back to the bottom of the interest list for an offer in the future, at the individual’s request; or
  • the ILR will be closed with the appropriate closure code in the CSIL database.

Review the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about MDCP ILRs for STAR Health members.

PSU staff must refer to:

  • Section 2100, Enrollment Following Release from the Interest List, for MDCP procedures following an individual’s release from the MDCP IL.
  • Section 2300, Interest List Release Closures, to request an individual previously on the MDCP IL be added back to the bottom of the IL.
  • Section 2310, Contacting the Interest List Management Unit to Reopen a Closed Interest List Release, for more information about processing IL reopen requests.

An individual requesting MDCP through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the ILM Unit. This request will not be considered a release from the IL, but instead as a referral of an individual interested in bypassing the IL through the MFP limited stay option.

PSU staff must refer to Section 2400, Money Follows the Person, for ILM procedures about the MFP processes.

2030 Program Support Unit Staff Responsibilities

Revision 18-0; Effective September 4, 2018

The Program Support Unit (PSU) staff are regional Texas Health and Human Services Commission (HHSC) staff responsible for facilitating the required components of the Medically Dependent Children Program (MDCP) eligibility process by coordinating between HHSC, managed care organizations (MCOs) and MDCP individuals. PSU staff document all coordination efforts in the individual’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.