Revision 18-0; Effective September 4, 2018

When Program Support Unit (PSU) staff receive the enrollment packet from the individual, PSU staff must review it to ensure all documents are completed.

If the enrollment packet is incomplete, PSU staff must contact the individual within two business days to obtain completed documents.

If the Medicaid for the Elderly and People with Disabilities (MEPD) specialist receives an unsigned Form H1200, Application for Assistance - Your Texas Benefits, from PSU staff with Form H1746-A, MEPD Referral Cover Sheet, the MEPD specialist returns Form H1200 to PSU staff with an annotation on Form H1746-A that Form H1200 is unsigned and must be signed before the Texas Health and Human Services Commission (HHSC) can establish a file date. Therefore, PSU staff must ensure Form H1200 is signed prior to referring to the MEPD specialist.

Once PSU staff receive notice of an unsigned application from the MEPD specialist, PSU staff must contact the individual within two business days to inform the individual of the need to return a signed application for processing.

Faxing unsigned applications delays the MEPD specialist’s eligibility determination process and could adversely affect service delivery to the individual.

2210 Income and Resource Verifications for Medicaid Eligibility

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must obtain a completed Form H1200, Application for Assistance – Your Texas Benefits, for medical assistance only (MAO) individuals or applicants. PSU staff must verify if Form H1200 is required for Medically Dependent Children Program (MDCP) eligibility by checking Appendix XVI, Medicaid Program Actions.

PSU staff must complete the following for individuals and applicants who require Form H1200 to determine MDCP eligibility:

  • Inform MAO individuals or applicants of the importance of providing Form H1200 and all required documents to the Medicaid for Elderly and People with Disabilities (MEPD) specialist;
  • Explain that failure to submit the required documentation to the MEPD specialist could result in a delay or denial of their application;
  • Fax Form H1200, Form H1746-A, MEPD Referral Cover Sheet, and any additional relevant financial information obtained, including information on third-party insurance, to the MEPD specialist if received;
  • Maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in Texas Integrated Eligibility Redesign System (TIERS); and
  • Maintain a copy of page one of Form H1200 in the applicant’s Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

Individuals and applicants with the appropriate type of Medicaid do not require Form H1200 [e.g., individuals and applicants with Supplemental Security Income (SSI)].

PSU staff must use Form H1746-A when communicating with the MEPD specialist. PSU staff must indicate the following on Form H1746-A, as applicable:

  • The individual or applicant is requesting MDCP;
  • The applicant is pending the medical necessity (MN) determination;
  • The applicant is pending the STAR Kids Individual Service Plan (SK-ISP); or
  • The applicant has an approved MN and SK-ISP.

PSU staff must fax a second Form H1746-A noting the applicant’s start of care (SOC) for MDCP if the applicant’s MN and SK-ISP were pending when the initial Form H1746-A was sent to the MEPD specialist.

The Texas Health and Human Services Commission (HHSC) Disability Determination Unit (DDU) staff may determine disability, pending the Social Security Administration (SSA) determination, if an MDCP individual’s or applicant’s application for SSI disability has been pending for more than 90 days. The SSI decision must be adopted upon receipt from SSA.

2210.1 Non-Medicaid Individual or Individual Enrolled in the Children’s Health Insurance Program

Revision 21-10; Effective October 25, 2021

Program Support Unit (PSU) staff must complete the following activities within two business days from receiving the enrollment packet or confirmed interest in the Medically Dependent Children Program (MDCP) from the individual or legally authorized representative (LAR):

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, and upload it to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • Upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • Document the HEART case record.

PSU staff must complete the following activities within two business days following the receipt date of the signed Form H1200, Application for Assistance - Your Texas Benefits:

  • Fax the following documents to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist:
    • Form H1200;
    • Form H1746-A, MEPD Referral Cover Sheet, requesting a financial eligibility determination for MDCP; and
    • any other verification documents provided by the individual or LAR; and
  • Record the date Form H1200 was received from the applicant and the date PSU staff faxed Form H1200 to the MEPD specialist in the HEART case record;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must check the Texas Integrated Redesign System (TIERS) to verify Medicaid eligibility.

2210.2 Individual Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

An individual who receives Supplemental Security Income (SSI) or SSI-related Medicaid meets the Medicaid financial eligibility requirement for the Medically Dependent Children Program (MDCP).

Within two business days of receiving the enrollment packet or confirmed interest from the individual, legally authorized representative (LAR) or authorized representative (AR), Program Support Unit (PSU) staff must:

  • confirm the individual continues to receive SSI or SSI-related Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • confirm the STAR Kids enrollment in TIERS;
  • complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral. For Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to age one, born to Medicaid-eligible mothers, PSU staff will be required to indicate all zeros in Item No. 3, Social Security Number (SSN), in Section A of Form H3676 if the individual does not have an established SSN; and
  • upload enrollment packet documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

2210.3 Individual Enrolled in STAR Health

Revision 18-0; Effective September 4, 2018

See the Uniform Managed Care Manual (UMCM) for STAR Health members.

2210.4 Individual Receiving Other Types of Medicaid

Revision 18-0; Effective September 4, 2018

An individual who receives other types of Medicaid (non-Supplemental Security Income (SSI) related Medicaid), may or may not meet the Medicaid financial eligibility requirement for the Medically Dependent Children Program (MDCP).

Within two business days of receiving the enrollment packet or confirmed interest from the individual, legally authorized representative (LAR) or authorized representative (AR), Program Support Unit (PSU) staff must:

  • confirm the individual continues to receive Medicaid in the Texas Integrated Eligibility Redesign System (TIERS);
  • complete Section A, Referral/Assessment Authorization, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, and upload to TxMedCentral, following the instructions in Appendix IX, Naming Conventions. For Medicaid type of assistance (TOA) code 45, MA-Newborn Children, children up to age one, born to Medicaid-eligible mothers, PSU staff will be required to indicate all zeros in Item No. 3, Social Security Number (SSN), in Section A of Form H3676 if the individual does not have an established SSN;
  • fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist requesting the individual’s Medicaid type to be changed to Medically Dependent Children Program (MDCP) Medicaid; and
  • upload enrollment packet documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record.

The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool. PSU staff must upload the MEPD specialist’s email communication in the HEART case record.

2210.5 Individual with a Qualified Income Trust

Revision 22-2; Effective Sept. 5, 2022

An individual or applicant who has a qualified income trust (QIT) may be determined eligible for the Medically Dependent Children Program (MDCP) even though their income is greater than the special institutional income limit for the program. Income diverted to the trust does not count for the purposes of determining Medicaid financial eligibility by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. However, the total income (including income diverted to the trust) is considered for the calculation of copayment for MDCP services. An individual or applicant may be eligible for services if all other eligibility criteria are met, even if the amount they have available for copayment equals or exceeds the total cost of their STAR Kids individual service plan (SK-ISP). 

PSU staff must refer questions regarding QIT to Access and Accessibility Services (AES) by generating and faxing Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist.

2220 Managed Care Organization Coordination

Revision 18-0; Effective September 4, 2018

The STAR Kids managed care organization (MCO) has 30 days following the initial notice from Program Support Unit (PSU) staff to complete all assessments for an individual enrolled in the Medically Dependent Children Program (MDCP). The MCO has an additional 30 days to submit all required documentation in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, for a total of 60 days following the initial notice from PSU staff. The MCO must:

  • verify the individual meets all other eligibility criteria referenced in the STAR Kids HandbookSection 1000, Overview and Eligibility;
  • complete Section B, Waiver Assessment Report, of Form H3676, Managed Care Pre-Enrollment Assessment Authorization;
  • complete the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items; and
  • complete Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, and submit electronically through the TMHP LTC Online Portal. For MAO individuals, complete Form 2604 and post to TexMedCentral.

If the MCO does not submit Form 2604 within 60 days after PSU staff posted Form H3676, Section A, authorizing the MCO to begin the eligibility process, PSU staff must email Managed Care Compliance & Operations (MCCO) to notify them of the MCO delinquency.

The MCO must schedule and complete the SK-SAI, including the MDCP module and record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG, within 30 days of notice from PSU staff. Once the SK-SAI is complete, the MCO must submit the results from the SK-SAI to TMHP, by posting to TMHP LTC Online Portal within 72 hours of completion. For the purposes of this requirement, a SK-SAI is considered "complete" when the MCO has obtained the physician’s signature on Form 2601, Physician Certification, and retains Form 2601 in the individual’s case file at the MCO.

A determination of medical necessity (MN) must be based on information collected as part of the SK-SAI and NCAM module (record SK-SAI items Z5a and Z5b as “Yes” (indicated by a "1") to ensure processing for MN and RUG). The MN determination must be approved by TMHP staff before an individual can be authorized for MDCP services.

TMHP staff processes the SK-SAI for an individual to determine MN and calculate a Resource Utilization Group (RUG). A RUG is a measure of nursing facility (NF) staffing intensity and is used in §1915(c) Medicaid waiver programs to categorize needs for an individual or member and establish the individual service plan (ISP) cost limit.

Once TMHP staff process the SK-SAI, the MCO will receive a substantive response file with a three-alphanumeric digit RUG value. This code may also be viewed in the TMHP LTC Online Portal. An SK-SAI with incomplete information will result in a “BC1” code instead of a RUG value. A“BC1” code indicates the SK-SAI does not have all of the information necessary for TMHP staff to accurately calculate a RUG for the individual 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 days of submitting the assessment that resulted in a “BC1” code. If the MCO fails to submit the correction within 14 days, the MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTC Online Portal. Information about the process of transmitting and correcting a SK-SAI is available in Appendix I, MCO Business Rules for SK-SAI and SK-ISP.

The MDCP module of the SK-SAI (Section R, MDCP Related Items) establishes an annual cost limit for each individual or member receiving MDCP services. The cost limit is based on the anticipated cost of the individual/member residing in an NF.

As a part of the ISP planning process, the MCO must establish an MDCP ISP that does not exceed the individual’s cost limit. If the MCO does not properly establish this plan of care (POC) and the individual or member’s ISP cost exceeds the individual limit, the MCO must continue to provide MDCP services at the MCO’s expense.

The MCO may not terminate MDCP enrollment if an individual or member’s ISP exceeds the cost limit. The MCO must also adopt a methodology to track each member’s MDCP-related expenditures on a monthly basis and provide an update on MDCP-related expenditures to the member, legally authorized representative (LAR) or authorized representative (AR) no less than once per month.

Service authorizations for MDCP must include the amount, frequency and duration of each service to be provided, and the schedule for when services will be rendered. The MCO must ensure the MDCP member does not experience gaps in authorizations and authorizations are consistent with information in the member’s ISP.

The member’s MDCP ISP Narrative must include the components of a person-centered ISP, as described in Title 42 Code of Federal Regulations (CFR) §441.301(c)(2) Subpart G, Contents of Request for a Waiver.

2230 Program Support Unit Staff Coordination for an Applicant Enrolling in MDCP

Revision 18-0; Effective September 4, 2018

Within two business days of receiving Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool, in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, Program Support Unit (PSU) staff must ensure the applicant has met all the following eligibility criteria:

  • is under age 21 in the Texas Integrated Eligibility Redesign System (TIERS);
  • is a Texas resident in TIERS;
  • has an approved medical necessity (MN) in the TMHP LTC Online Portal;
  • has an individual service plan (ISP) with at least one Medically Dependent Children Program (MDCP) service; and
  • has an ISP within the individual’s cost limit.

For an applicant needing a Medicaid eligibility financial decision, PSU staff must also notify the Medicaid for the Elderly and People with Disabilities (MEPD) specialist within two business days that the applicant meets MN and document this notification in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. This notification must be documented on Form H1746-A, MEPD Referral Cover Sheet, and faxed within two business days to the MEPD specialist.

The MEPD specialist will notify PSU staff of the financial eligibility determination through the MEPD Communication Tool. PSU staff must upload the MEPD specialist’s determination in the HEART case record.

The start of care (SOC) date for MDCP services is the first day of the month following the applicant meeting all the eligibility criteria.

Example: If a managed care organization (MCO) submits all eligibility criteria on March 1 and PSU staff verifies the applicant meets all eligibility criteria on March 3, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month following the applicant meeting all eligibility criteria. The eligibility date on Form H2065-D, Notification of Managed Care Program Services, will be April 1.

Example: If an MCO submits all eligibility criteria on March 31 and PSU staff verifies the applicant meets all eligibility criteria on April 2, the SOC date is April 1. The SOC is April 1 because services begin the first day of the month following the applicant meeting all eligibility criteria. The eligibility date on Form H2065-D will be April 1. The individual met the eligibility criteria on March 31. Delay in services must not occur due to PSU staff processing times.

Eligibility must be approved by PSU staff within two business days of the applicant meeting all eligibility criteria and receiving Form H3676 and Form 2604 from the MCO. PSU staff must generate Form H2065-D in the TMHP LTC Online Portal and:

  • mail the original Form H2065-D to the applicant;
  • email Enrollment Resolution Services (ERS) the following information:
    • the applicant’s name;
    • Medicaid identification (ID) number;
    • type of request (interest list or Money Follows the Person (MFP));
    • date of MFP limited nursing facility (NF) stay, if applicable;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment; and
    • Form H2065-D;
  • document the interest list closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable documents to HEART case record and close the HEART case record using the appropriate closure code.

The MCO must monitor the TMHP LTC Online Portal for the status of the member’s ISP and to retrieve Form H2065-D.

2240 Reserved For Future Use

Revision 22-3; Effective Sept. 9, 2022