2000, Medically Dependent Children Program Intake and Initial Application

2001 Eligibility

Revision 21-10; Effective October 25, 2021

Title 1 Texas Administrative Code (TAC) §353.1155 applies to Medically Dependent Children Program (MDCP) services provided under a Medicaid managed care program. The managed care organization (MCO) must assess an individual’s functional eligibility for MDCP. To be eligible for MDCP, an individual must:

  • be under 21 years of age;
  • be a U.S. citizen and reside in Texas;
  • meet the level of care (LOC) criteria for medical necessity (MN) for nursing facility (NF) care as determined by 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 service;
  • not be receiving Community Care for the Aged and Disabled (CCAD) services;
  • choose MDCP as an alternative to nursing facility services, as described in 42 CFR §441.302(d);
  • not be enrolled in one of the following Medicaid Home and Community Based Services (HCBS) waiver programs:
    • Community Living Assistance and Support Services (CLASS);
    • Deaf Blind with Multiple Disabilities (DBMD);
    • Home and Community-based Services (HCS);
    • Texas Home Living (TxHmL); or
    • Youth Empowerment Services (YES); and
  • live in:
    • the individual’s home; or
    • an agency foster home as defined in the Texas Human Resource Code §42.002, (relating to Definitions); and
  • be determined by HHSC to be financially eligible for Medicaid, as described in Title 1 TAC §358 (relating to Medicaid Eligibility for the Elderly and People with Disabilities), and Title 1 TAC §361 (relating to Medicaid Buy-In for Children Program).

An individual receiving Medicaid NF services is approved for MDCP if the individual requests services while residing in an NF and meets the eligibility criteria listed above. If an individual is discharged from an NF into a community setting before being determined eligible for Medicaid, NF services and MDCP, the individual is denied immediate enrollment in the program.

HHSC maintains a statewide interest list of individuals interested in receiving services through MDCP. An individual or legally authorized representative (LAR) may request an individual's name to be added to the MDCP interest list by:

  • calling HHSC toll-free at 877-438-5658;
  • submitting a written request to HHSC; or
  • generating a referral through the YourTexasBenefits.com, Find Support Services screening and referral tool.

The ILM Unit will add an individual’s name to the MDCP interest list as requested above:

  • if the individual is a Texas resident; and
  • using the date HHSC receives the request as the MDCP interest list date.

HHSC removes an individual's name from the MDCP interest list if:

  • the individual is deceased;
  • the individual is assessed for MDCP and determined to be eligible or ineligible;
  • the individual or LAR requests the removal of the individual's name from the interest list; or
  • the individual moves out of Texas, unless the individual is a military family member living outside of Texas as described in Texas Government Code §531.0931:
    • while the military member is on active duty; or
    • for less than one year after the former military member's active duty ends.

An individual or LAR may request placement at the bottom of the interest list immediately following a determination of ineligibility for MDCP.

The MCO develops a person-centered STAR Kids Individual Service plan (SK-ISP) for each member enrolled in MDCP. All applicable documentation, as described in the STAR Kids Handbook (SKH), the Uniform Managed Care Manual (UMCM) and managed care contracts, must be in the member’s case file maintained by the MCO. The SK-ISP must:

  • include services described in the waiver;
  • include services necessary to protect the member's health and welfare in the community;
  • include services that supplement rather than supplant the member's natural supports and other non-MDCP supports and services for which the member may be eligible;
  • include services designed to prevent the member's admission to an institution;
  • include the most appropriate type and amount of services to meet the member's needs in the community;
  • be reviewed and revised if a member's needs or natural supports change or at the request of the member or LAR;
  • be approved by HHSC; and
  • be under the annual cost limit.

The MCO must submit a request for a clinical assessment to HHSC if a member's SK-ISP exceeds 50 percent of the cost of the member's LOC in a NF to safely serve the member's needs in the community.

HHSC Utilization Review (UR) may request a clinical review of the case to consider the use of state general revenue funds to cover costs exceeding 50 percent of the cost limit. HHSC will provide a copy of the final determination letter to the MCO and the Program Support Unit (PSU) if a clinical review is conducted. PSU staff must refer to Section 3324, Individual Service Plan Exceeding Cost Limit for MDCP Services, for information about exceeding the MDCP cost limit.

The MCO is responsible for conducting initial assessments, reassessments and developing the SK-ISP to determine eligibility for MDCP. The MCO must follow the policies and procedures outlined in the SKH, UMCM, managed care contracts and materials designated by HHSC.

A member participating in MDCP has the same rights and responsibilities as an individual enrolled in managed care, as described in Title 1 TAC §353, Subchapter C  (relating to Member Bill of Rights and Responsibilities), including the right to appeal a decision made by HHSC or an MCO and the right to a fair hearing, as described in Title 1 §357, Subchapter A , of this title (relating to Uniform Fair Hearing Rules). HHSC conducts utilization reviews of STAR Kids MCOs as described in Texas Government Code §533.00281.

 

2002 Medical Necessity

Revision 21-10; Effective October 25, 2021

Title 26 Texas Administrative Code (TAC) §554.2401 applies to the medical necessity (MN) requirements for participation in the Medicaid (Title XIX) Long-term Care program to include the Medically Dependent Children Program (MDCP). To verify that MN exists, an individual must meet the following conditions:

  • 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 a licensed nurse’s supervision, assessment, planning and intervention that are available only in an institution; and
  • 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.

 

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 21-10; Effective October 25, 2021
 
Interest List Management (ILM) Unit staff are Texas Health and Human Services Commission (HHSC) staff responsible for maintaining and releasing individuals from the Medically Dependent Children Program (MDCP) interest list. ILM Unit staff must use the Community Services Interest List (CSIL) database to track individuals who request the MDCP program. ILM Unit staff must release individuals from the MDCP program interest list as slots become available in the program.

ILM Unit staff perform the following activities for individuals who request placement on the MDCP interest list:

  • Place individuals on the interest list;
  • Maintain annual contact requirements;
  • Release individuals from the interest list when funding is available; and
  • Confirm individuals on the interest list 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;
    • confirming Texas residency; and
    • verifying the individual is still interested in the MDCP.

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

ILM Unit staff perform the following activities upon an individual’s release from the MDCP interest list:

  • Verify the individual’s Medicaid type of assistance (TOA) in TIERS, if applicable;
  • Contact the individual by phone to notify them of reaching the top of the interest list;
  • Confirm continued interest in MDCP;
  • Provide a general description of MDCP services;
  • Discuss managed care organizations (MCOs) operating in the individual’s service area (SA);
  • Encourage the individual to contact the MCO for additional information and available services, if applicable;
  • Create a Program Support Unit (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.

See the Uniform Managed Care Manual (UMCM) §16.2 for specific requirements regarding MDCP interest list releases 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 interest list.

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

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