2410 Traditional Money Follows the Person

Revision 23-3; Effective May 22, 2023

The Money Follows the Person (MFP) procedure allows Medicaid-eligible nursing facility (NF) residents to receive services in the community by transitioning to long-term services and supports (LTSS). The managed care organization (MCO) performs the functional assessment and service planning for residents who need the Medically Dependent Children Program (MDCP) services upon discharge from the NF.

Individuals in an NF are assigned permanency planners. The permanency planner coordinates permanency planning through the traditional MFP process into MDCP. The state-contracted permanency planner is EveryChild Inc. 

Permanency planning is:

  • the placement process for a child in an NF; and
  • "A philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement with the primary feature of an enduring and nurturing parental relationship." (Title 4 Texas Government Code Section 531.151). 

An individual receiving NF Medicaid must request MDCP while living in an NF and remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

An individual without Medicaid must:

  • request MDCP while residing in an NF;
  • reside in an NF for no less than 30 days or until Medicaid eligibility is approved; and
  • remain in the NF until PSU staff make a final eligibility determination for MDCP.

PSU staff must refer to Section 2411, Medically Dependent Children Program Eligibility, and 2411.1, Texas Administrative Code Medically Dependent Children Program Eligibility Requirements, for more information about MDCP eligibility requirements.

Individuals who meet the medically fragile criteria and are not able to live in an NF for a minimum of 30 days or until Medicaid is approved may be able to enter MDCP through the MFP Limited NF stay process.

PSU staff must refer to Section 2420, Money Follows the Person Limited Nursing Facility Stay Option for a Medically Fragile Individual, for more information about the MFP limited NF stay process.

2411 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;
  • reside 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 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.

An individual receiving Medicaid NF services is approved for MDCP if: 

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

An individual without Medicaid eligibility must reside in an NF for no less than 30 days or until Medicaid eligibility is approved. 

An individual is denied immediate enrollment if the individual discharges from the NF before being determined eligible for MDCP. 

2411.1 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 in order 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: 
    • the person's home; or 
    • an agency foster home as defined in Texas Human Resource Code, Section 42.002, (relating to Definitions); and 
  • 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 residing in a NF; and 
  • meets the eligibility criteria listed above.  

2411.2 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 person must demonstrate a medical condition that: 
    • is sufficiently serious 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 available only 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.

PSU staff must refer to the following sections for the information about MN determination procedures for MDCP applicants pursing eligibility through the traditional Money Follows the Person (MFP) process: 

  • Section 2412.3, Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Managed Care Organization Coordination, for non-STAR Kids nursing facility residents; and
  • Section 2413.3, Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Managed Care Coordination, for STAR Kids nursing facility residents. 

2412 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents 

Revision 22-3; Effective Sept. 9, 2022 

The individual’s permanency planner, Every Child, Inc., contacts the Interest List Management (ILM) Unit within two business days from the individual’s Medically Dependent Children Program (MDCP) selection date to:

  • notify the Texas Health and Human Services Commission (HHSC) that the individual has selected MDCP through the traditional Money Follows the Person (MFP) process; and
  • update the individual’s address on file, if needed.

Note: Other entities may contact the ILM Unit to provide notification of an individual’s request to pursue MDCP through the traditional MFP process. These entities may include the:

  • legally authorized representative (LAR);
  • individual; or 
  • nursing facility (NF). 

2412.1 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Interest List Management Responsibilities 

Revision 22-3; Effective Sept. 9, 2022 

Interest List Management (ILM) Unit staff complete the following activities for a non-STAR Kids nursing facility (NF) individual who requests to pursue the Medically Dependent Children Program (MDCP) through the traditional Money Follows the Person (MFP) process:

  • create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database; or
  • add the individual to the interest list if they are not on the interest list;
  • immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • assign the MDCP case record in HEART to Program Support Unit (PSU) staff. 

2412.2 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit Responsibilities

Revision 22-3; Effective Sept. 9, 2022

 

2412.2.1 Enrollment Following Interest List Release Bypass 

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days of the receipt of a traditional Money Follows the Person (MFP) Medically Dependent Children Program (MDCP) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and document the Medicaid type; 
  • determine if Form H1200, Application for Assistance – Your Texas Benefits, is required in the enrollment packet;
    • refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200 to determine Medicaid financial eligibility;
  • contact or attempt to contact the individual or legally authorized representative (LAR) by phone to explain the: 
    • Medicaid application process, if applicable; 
    • importance of selecting a STAR Kids managed care organization (MCO); and
    • the importance of promptly returning the enrollment packet, if applicable;
  • mail the following enrollment packet to the individual or LAR:
  • •upload the applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

PSU staff must contact the individual or LAR within 14 days after mailing the enrollment packet to:

  • verify receipt of the enrollment packet;
  • explain the Medicaid application process, if applicable;
  • give a general description of MDCP services;
  • explain the need to select a STAR Kids MCO within 30 days from the mail date of the above enrollment packet;
  • inform the individual or LAR that a delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP;
  • encourage the individual or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual: 
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, if applicable; and
  • advise the individual, LAR or nursing facility (NF) to immediately submit Form H1200 if: 
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • TIERS does not have a record of submission; and
  • document all contact attempts and any delays in the HEART case record. 

PSU staff must check TIERS to verify Form H1200 has been submitted if the applicant, LAR or NF states Form H1200 has already been submitted during the 14-day follow-up contact.

PSU staff must fax Form 1746-A, MEPD Referral Cover Sheet, and Form H1200 to the Medicaid for Elderly and Persons with Disabilities (MEPD) specialist within two business days from locating Form H1200 in TIERS without Form H1746-A, if applicable. PSU staff must notate the following on Form H1746-A:

  • Form H1200 is in TIERS; and
  • the applicant is requesting to pursue the MFP process.

PSU staff must review the enrollment packet upon receipt to ensure all documents are completed. PSU staff must complete the following activities within two business days from the date Form H1200 is received:

  • fax Form H1746-A and Form H1200 to the MEPD specialist;
  • notate the applicant is requesting to pursue the MFP process on From H1746-A;
  • 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;
  • maintain a copy of Form H1200 until PSU staff can verify Form H1200 is received in TIERS; 
  • check TIERS to determine if Form H1200 is received;
  • maintain a copy of page one of Form H1200 in the applicant’s 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 ensure Form H1200 is signed prior to faxing Form H1200 to the MEPD specialist, if applicable. The MEPD specialist will return the unsigned Form H1200 to PSU staff requesting the applicant or LAR’s signature before processing the application. 

PSU staff must complete the following activities within two business days from notification by the MEPD specialist that Form H1200 is unsigned:

  • contact the applicant or LAR;
  • advise that the application cannot be processed unless Form H1200 is signed; and
  • document the HEART case record.

PSU staff may complete the following activities within two business days from the date PSU staff received an unsigned Form H1200: 

  • generate Form 2606, Managed Care Enrollment Processing Delay, and Form 2606-S;
  • mail Form 2606 with the original unsigned Form H1200 to the applicant; and
  • document the HEART case record.
  • PSU staff must complete the following activities if Form 2606 was mailed:
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document the HEART case record.

PSU staff must check TIERS to verify if Form H1200 and Form H1746-A is received, as applicable. 

PSU staff must document all contact attempts and any delays in the HEART case record. 

The MEPD specialist has 45 days (or up to 90 days if it is necessary to obtain a disability determination) to complete the application process.  

2412.2.2 Managed Care Organization Selection or Default

Revision 22-3; Effective Sept. 9, 2022 

Non-STAR Kids nursing facility (NF) residents pursing the Medically Dependent Children Program (MDCP) though the traditional Money Follows the Person (MFP) process must select a STAR Kids managed care organization (MCO). Program Support Unit (PSU) staff may accept an individual, applicant or legally authorized representative’s (LAR’s) verbal or written STAR Kids MCO selection. The individual, applicant or LAR may provide their written STAR Kids MCO selection on Form H2053-B, Health Plan Selection.

Individuals and applicants have 30 days from the enrollment packet mail date to select a STAR Kids MCO. PSU staff must default the individual or applicant to a STAR Kids MCO if an MCO selection is not received within 30 days from the enrollment packet mail date. The defaulted MCO must be in the individual or applicant’s service area (SA). 

PSU must document all contact attempts and case actions in the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. 

2412.2.3 Receipt of Enrollment Packet 

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days from:

  • receiving the completed enrollment packet from a non-STAR Kids nursing facility (NF) resident pursing the Medically Dependent Children Program (MDCP) though the traditional Money Follows the Person (MFP) process; or 
  • a STAR Kids managed care organization (MCO) selection or default:
    • complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating the individual or applicant requests the traditional Money Follows the Person (MFP) option;
    • upload Form H3676, Section A, 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 contact the individual or legally authorized representative (LAR) within two business days from the receipt of an enrollment packet that is incomplete, incorrect, or missing information to:

  • obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • obtain missing or corrected information required to process the case if information is missing or incorrect;
  • encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual: 
    • has not selected a STAR Kids MCO; or
    • has not provided Form H1200, Application for Assistance – Your Texas Benefits, if applicable; and
  • advise the individual or LAR to immediately submit Form H1200 if: 
    • the individual requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in the Texas Integrated Redesign System (TIERS).

PSU must document all contact attempts in the HEART case record.

PSU staff may complete the following activities within two business days from the 30th day of the enrollment packet mail date if the applicant has not returned Form H1200:

  • generate Form 2606, Managed Care Enrollment Processing Delay, and Form 2606-S;
  • mail Form 2606 with the original unsigned Form H1200 to the applicant; and
  • document the HEART case record.
  • PSU staff must complete the following activities if Form 2606 was mailed:
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document the HEART case record. 

2412.3 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Managed Care Organization Coordination

Revision 22-3; Effective Sept. 9, 2022 

The managed care organization (MCO) initiates contact with the individual, applicant, or legally authorized representative (LAR) to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO must complete the STAR Kids Individual Assessment Instrument (SK-SAI) within 30 days from the date Program Support Unit (PSU) staff uploaded Form H3676, Section A, to TxMedCentral. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification. The MCO must submit the SK-SAI to the Texas Health and Human Services (HHSC) Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 72 hours of the assessment’s completion.

TMHP staff process the SK-SAI to determine medical necessity (MN) and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used to establish the STAR Kids individual service plan (SK-ISP) cost limit.

The MCO must correct the information on the SK-SAI within 14 days of submitting an SK-SAI with an error. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP if the MCO fails to submit the correction within 14 days.

The MCO has an additional 30 days to submit all required documentation to PSU staff. The MCO must complete the following activities within 60 days from the receipt of Form H3676, Section A:

  • complete Form H3676, Section B and upload it to TxMedCentral;
  • complete the SK-SAI in the TMHP LTCOP; 
  • obtain the applicant’s physician's signature on Form 2601;
  • complete the SK-ISP; and
  • submit the SK-ISP electronically through the TMHP LTCOP.

PSU staff must monitor TxMedCentral and the TMHP LTCOP, as applicable, for receipt of the completed:

  • Form H3676, Section B; 
  • SK-ISP; and 
  • SK-SAI.

The MCO must complete and submit the SK-SAI and SK-ISP before the NF discharge.

PSU staff must fax Form H1746-A, MEPD Referral Cover Sheet, to the Medicaid for the Elderly and Persons with Disabilities (MEPD) specialist to notify the MEPD specialist within two business days of the receipt of:

  • a valid SK-ISP; and
  • the SK-SAI if Medicaid is still pending. 

PSU staff must notate the following on Form H1746-A:

  • The applicant has an approved MN; and
  • The applicant has a valid SK-ISP.

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

PSU staff must email the Program Support Operations Review Team (PSORT) mailbox within two business days from the date the MCO fails to submit the initial assessment information within the 60-day timeframe. The email must include: 

  • an email subject line that reads: “MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for Ann Smith would read “MDCP Initial 60-Day 9B MCO Non-Compliance for AS.”
  • the following items in the body of the email:
    • individual or applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code; 
    • the date information was due from the MCO; 
    • a brief description of the delay and any MCO information received; and
  • attachments of any pertinent documents received from the MCO (e.g., Form H2067-MC, Managed Care Programs Communication).

PSU staff must continue to monitor TxMedCentral and the TMHP LTCOP for receipt of the above information. PSU staff must email any case information received from the MCO to the PSORT mailbox within two business days from its receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late initial assessment information. PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • SSN or Medicaid ID number;
    • DOB;
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.
  • PSU staff must: 
  • collaborate, as needed, with all involved parties throughout the MDCP eligibility determination process to assist with problem resolution and to document delays;
  • track all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record. 

2412.4 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Program Support Unit Staff Coordination 

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities in one business day following the receipt of all documentation required for the Medically Dependent Children Program (MDCP) eligibility, as well as the Medicaid financial eligibility determination, as applicable:

  • confirm MDCP eligibility by verifying the applicant: 
    • is under 21 years old in the Texas Integrated Eligibility Redesign System (TIERS);
    • is a Texas resident in TIERS;
    • has the appropriate Medicaid type of assistance (TOA) for MDCP in TIERS;
    • has an approved medical necessity (MN) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
    • has a STAR Kids individual service plan (SK-ISP): 
      • with a least one MDCP service; and 
      • within the applicant's cost limit; 
  • manually generate the initial Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
  • PSU staff must refer to Form H2065-D instructions for more information on field entries;
  • mail the initial Form H2065-D to the applicant or legally authorized representative (LAR);
  • upload Form H2065-D 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 Report and Tracking System (HEART) case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

The managed care organization (MCO) collaborates with the applicant, LAR, and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within two business days from determining the discharge date.

PSU staff must upload Form H2067-MC to TxMedCentral following the instructions in Appendix IX within two business days from notification by another entity of a different nursing facility (NF) discharge date. PSU staff must request the MCO confirm which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to TxMedCentral advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to TxMedCentral within two business days before the applicant’s planned NF discharge date to confirm the applicant’s planned discharge date remains the same. The MCO will provide PSU staff with the new NF discharge date if the planned NF discharge date has changed.

PSU staff must complete the following activities within one business day after the NF discharge notification date:

  • approve the SK-ISP in the TMHP LTCOP;
  • electronically generate the final Form H2065-D following the instructions in Appendix II;
    • PSU staff must refer to Form H2065-D instructions for more information on field entries.
    • The start of care (SOC) date is the first of the month in which the discharge occurred. 
  • mail the final Form H2065-D to the member or LAR;
  • upload the final Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
  • fax Form H1746-A, MEPD Referral Cover Sheet, and Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, if applicable;
  • email Enrollment Resolution Services (ERS) requesting MDCP enrollment. The email must include the following information: 
    • an email subject line that reads, “MDCP MFP Enrollment Request for XX [first letter of the member's first and last name].” For example, the email subject line for a traditional MDCP Money Follows the Person (MFP) enrollment request for Ann Smith would be “MDCP MFP Enrollment Request for AS;”
    • the member's name;
    • Medicaid identification (ID) number;
    • the type of request (i.e., MFP NF discharge);
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • effective date of enrollment; 
    • MN approval date;
    • MCO selection; and
    • Form H2065-D; 
  • close the Community Services Interest List (CSIL)
  • database record using the appropriate closure code; 
  • upload all applicable documents to the HEART case record following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

2412.5 Traditional Money Follows the Person Non-STAR Kids Nursing Facility Residents: Denials 

Revision 23-3; Effective May 22, 2023

An individual without Medicaid must:

  • request the Medically Dependent Children Program (MDCP) while living in a nursing facility (NF);
  • live in an NF for no less than 30 days or until Medicaid eligibility is approved; and
  • remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

The managed care organization (MCO) must upload Form H3676, Care Pre- Enrollment Assessment Authorization, Section B, to TxMedCentral, within two business days from determining the applicant has failed to meet any MDCP eligibility criteria.

PSU staff must deny the MDCP Money Follows the Person (MFP) applicant by manually generating Form H2065-D, Notification of Managed Care Program Services, within two business days from MCO notification if the MDCP MFP applicant has not: 

  • met MDCP eligibility; or 
  • completed the MFP process.

PSU staff must follow the instructions in Appendix II, Form H2065-D MD CP Reason for Denial and Comments Language, when manually generating Form H2065-D.

PSU staff must refer the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the denial of MDCP for STAR Health applicants.

PSU staff must refer to Section 6000, Denials and Terminations, for more information about processing MDCP applicant denials.

PSU staff must notify the Interest List Management (ILM) Unit staff by email at MDCP_Interest_List@hhsc.state.tx.us for all MDCP MFP individuals or applicants who do not meet the MDCP MFP eligibility requirements. The email must include the following information:

  • an email subject line that reads: "MDCP MFP Denial for XX [first letter of the individual’s or applicant’s first and last name]." For example, the email subject line for an MFP denial for Ann Smith would be "MDCP MFP Denial for AS;"
  • the individual or applicant’s name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • contact name and phone number; 
  • the reason for the denial; and
  • the request to return the individual or applicant to the MDCP interest using their original MDCP request date.

PSU staff must not close the Community Services Interest List (CSIL) record for an MDCP MFP applicant.

PSU staff must not:

  • deny MDCP for an MDCP MFP individual; 
  • close the CSIL record for an MDCP MFP individual; or
  • generate and mail Form 2442, Notification of Interest List Release Closure for an MDCP MFP individual.

PSU staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for more information about scenarios where an individual, applicant or member transitions out of MDCP for not meeting the MDCP age requirement.

2413 Traditional Money Follows the Person STAR Kids Nursing Facility Residents

Revision 22-3; Effective Sept. 9, 2022

An individual’s permanency planner, Every Child, Inc., contacts the Interest List Management (ILM) Unit within two business days from the individual’s Medically Dependent Children Program (MDCP) selection date to:

  • notify the Texas Health and Human Services Commission (HHSC) that the individual has selected MDCP under the traditional Money Follows the Person (MFP) process; and
  • update the individual’s address on file, if needed.

Note: Other entities may contact the ILM Unit to provide notification of an individual’s request to pursue MDCP through the traditional MFP process. These entities may include:

  • legally authorized representative (LAR);
  • individual; or 
  • nursing facility (NF). 

2413.1 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Interest List Management Responsibilities

Revision 22-3; Effective Sept. 9, 2022 

Interest List Management (ILM) Unit staff complete the following activities for a STAR Kids nursing facility (NF) individual who requests to pursue the Medically Dependent Children Program (MDCP) through the traditional Money Follows the Person (MFP) process:

  • create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database; or
  • add the individual to the interest list if they are not on the interest list;
  • immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • assign the MDCP case record in HEART to Program Support Unit (PSU) staff. 

2413.2 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Responsibilities

Revision 22-3; Effective Sept. 9, 2022

 

2413.2.1 Enrollment Following Interest List Release Bypass

Revision 22-3; Effective Sept. 9, 2022 

Program Support Unit (PSU) staff must complete the following activities within two business days of the receipt of a traditional Money Follows the Person (MFP) Medically Dependent Children Program (MDCP) case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART):

  • check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility and document the Medicaid type; 
  • mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A, indicating:
    • the individual or applicant is enrolled in STAR Kids; and
    • requests the traditional Money Follows the Person (MFP) option; 
  • upload Form H3676, Section A, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record.

PSU staff must contact the individual or LAR within 14 days after mailing the enrollment packet to: 

  • verify receipt of the enrollment packet; and
  • provide a general description of MDCP services.

2413.3 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Managed Care Coordination

Revision 22-3; Effective Sept. 9, 2022 

The managed care organization (MCO) initiates contact with the individual, applicant, or legally authorized representative (LAR) to begin the assessment process within 10 business days of receipt of Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A.

The MCO must complete the STAR Kids Individual Assessment Instrument (SK-SAI) within 30 days from the date Program Support Unit (PSU) staff uploaded Form H3676, Section A, to TxMedCentral. The SK-SAI is considered complete upon MCO’s receipt of the Form 2601, Physician Certification. The MCO must submit the SK-SAI to the Texas Health and Human Services Commission (HHSC) Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) within 72 hours of the assessment’s completion.

TMHP staff process the SK-SAI to determine medical necessity (MN) and calculate a Resource Utilization Group (RUG) value. A RUG value is a measure of nursing facility (NF) staffing intensity and is used to establish the STAR Kids individual service plan (SK-ISP) cost limit.

The MCO must correct the information on the SK-SAI within 14 days of submitting an SK-SAI with an error. The MCO must inactivate the SK-SAI and resubmit the assessment with correct information to the TMHP LTCOP if the MCO fails to submit the correction within 14 days.

The MCO has an additional 30 days to submit all required documentation to PSU staff. The MCO must complete the following activities within 60 days from the receipt of Form H3676, Section A:

  • Form H3676, Section B and upload it to TxMedCentral;
  • the SK-SAI in the TMHP LTCOP; 
  • the SK-ISP; 
  • obtain the applicant’s physician's signature on Form 2601; and
  • submit the SK-ISP electronically through the TMHP LTCOP.

PSU staff must monitor TxMedCentral and the TMHP LTCOP, as applicable, for receipt of the completed:

  • Form H3676, Section B; 
  • SK-ISP; and 
  • SK-SAI.

The MCO must complete and submit the SK-SAI and SK-ISP before the NF discharge.

PSU staff must email the Program Support Operations Review Team (PSORT) mailbox within two business days from the date the MCO fails to submit the initial assessment information within the 60-day timeframe. The email must include: 

  • an email subject line that reads: “MDCP Initial 60-Day XX [plan code] MCO Non-Compliance for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for Ann Smith would read “MDCP Initial 60-Day 9B MCO Non-Compliance for AS.”
  • the following items in the body of the email:
    • individual’s or applicant’s name;
    • Social Security number (SSN) or Medicaid identification (ID) number;
    • date of birth (DOB);
    • name of the MCO and plan code; 
    • the date information was due from the MCO; 
    • a brief description of the delay and any MCO information received; and
    • attachments of any pertinent documents received from the MCO (e.g., Form H2067-MC, Managed Care Programs Communication)

PSU staff must continue to monitor TxMedCentral and the TMHP LTCOP for receipt of the above information. PSU staff must email any case information received to the PSORT mailbox within two business days of receipt. The follow-up email must include the same email identifier elements listed above.

PSU staff must continue to email the Texas Health and Human Services Commission (HHSC) Managed Care Contracts and Oversight (MCCO) Unit staff for MCO non-compliance issues that are unrelated to late initial assessment information.

PSU staff must include the following components when emailing MCCO Unit staff:

  • an email subject line that reads: “MDCP MCO Non-Compliance for XX [first letter of the member’s first and last name].” For example, the email subject line for an MDCP MCO non-compliance for Ann Smith would read “MDCP MCO Non-Compliance for AS”;
  • the following items in the body of the email:
    • applicant or member’s name;
    • SSN or Medicaid ID number;
    • DOB;
    • name of the MCO and plan code;
    • the date information was due from the MCO; 
    • a brief description of the MCO non-compliance and any MCO information received; and
  • attachments of any pertinent documents received from the MCO, if applicable.

PSU staff must: 

  • collaborate, as needed, with all involved parties throughout the Medically Dependent Children Program (MDCP) eligibility determination process to assist with problem resolution and to document delays;
  • track all actions and communications in the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record;
  • upload applicable documents to the HEART case record, following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions; and
  • document the HEART case record. 

2413.4 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Program Support Unit Staff Coordination

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff must complete the following activities within one business day following the receipt of all documentation required for Medically Dependent Children Program (MDCP) eligibility:

  • confirm MDCP eligibility by verifying the applicant: 
    • is under 21 years old in the Texas Integrated Eligibility Redesign System (TIERS);
    • is a Texas resident in TIERS;
    • has the appropriate Medicaid type of assistance (TOA) for MDCP in TIERS;
    • has an approved medical necessity (MN) in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP);
    • has a STAR Kids individual service plan (SK-ISP): 
      • with a least one MDCP service; and
      • within the applicant’s cost limit;
    • manually generate the initial Form H2065-D, Notification of Managed Care Program Services, following the instructions in Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language;
      • PSU staff must refer to Form H2065-D instructions for more information on field entries;
    • mail the initial Form H2065-D to the applicant or legally authorized representative (LAR);
    • upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions;
    • upload all applicable documents to the (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.

The managed care organization (MCO) collaborates with the applicant, LAR, and PSU staff to identify a proposed discharge date. The MCO must upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral within two business days from determining the discharge date.

PSU staff must upload Form H2067-MC to TxMedCentral, following the instructions in Appendix IX, within two business days from notification by another entity of a different nursing facility (NF) discharge date. PSU staff must request the MCO confirm which discharge date is acceptable. The MCO must respond within two business days by uploading Form H2067-MC to TxMedCentral advising of the correct scheduled discharge date.

The MCO must upload Form H2067-MC to TxMedCentral within two business days before the applicant’s planned NF discharge date to confirm the applicant’s planned discharge date remains the same. The MCO must provide PSU staff with the new NF discharge date if the planned NF discharge date has changed.

PSU staff must complete the following activities within one business day following the NF discharge notification date: 

  • approve the SK-ISP in the TMHP LTCOP;
  • electronically generate the final Form H2065-D; following the instructions in Appendix II;
    • PSU staff must refer to Form H2065-D instructions for more information on field entries.
    • The start of care (SOC) date is the first of the month in which the discharge occurred. 
  • mail the final Form H2065-D to the member or LAR;
  • upload the final Form H2065-D to TxMedCentral, following the instructions in Appendix IX, if generated manually;
  • email Enrollment Resolution Services (ERS), requesting MDCP enrollment. The email must include the following information: 
    • an email subject line that reads, “MDCP MFP Enrollment Request for XX [first letter of the member's first and last name].” For example, the email subject line for a traditional MDCP Money Follows the Person (MFP) enrollment request for Ann Smith would be “MDCP MFP Enrollment Request for AS;” 
    • the member’s name;
    • Medicaid identification (ID) number;
    • type of request (i.e., MFP NF discharge);
    • SK-ISP receipt date;
    • SK-ISP begin date;
    • SK-ISP end date;
    • effective date of enrollment;
    • MN approval date;
    • MCO; and
    • Form H2065-D; 
  • close the Community Services Interest List (CSIL) database record using the appropriate closure code;
  • upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • document and close the HEART case record.

2413.5 Traditional Money Follows the Person STAR Kids Nursing Facility Residents: Denials

Revision 23-3; Effective May 22, 2023

An individual receiving nursing facility (NF) Medicaid must request the Medically Dependent Children Program (MDCP) while residing in an NF and remain in the NF until Program Support Unit (PSU) staff make a final eligibility determination for MDCP.

The managed care organization (MCO) must upload Form H3676, Care Pre- Enrollment Assessment Authorization, Section B, to TxMedCentral, within two business days from determining the applicant has failed to meet any MDCP eligibility criteria.

PSU staff must deny the MDCP Money Follows the Person (MFP) applicant by manually generating Form H2065-D, Notification of Managed Care Program Services, within two business days from MCO notification if the MDCP MFP applicant has not: 

  • met MDCP eligibility; or 
  • completed the MFP process.

PSU staff must follow the instructions in Appendix II, Form H2065-D MD CP Reason for Denial and Comments Language, when manually generating Form H2065-D.

PSU staff must refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the denial of MDCP for STAR Health applicants.

PSU staff must refer to Section 6000, Denials and Terminations, for more information about processing MDCP applicant denials.

PSU staff must notify the Interest List Management (ILM) Unit staff by email at MDCP_Interest_List@hhsc.state.tx.us for all MDCP MFP individuals or applicants who do not meet the MDCP MFP eligibility requirements. The email must include the following information:

  • an email subject line reads: “MDCP MFP Denial for XX [first letter of the individual’s or applicant’s first and last name].” For example, the email subject line for an MFP denial for Ann Smith would be “MDCP MFP Denial for AS;”
  • the individual or applicant's name;
  • Medicaid identification (ID) number or Social Security number (SSN);
  • contact name and phone number; 
  • the reason for the denial; and
  • the request to return the individual or applicant to the MDCP interest list using their original MDCP request date.

PSU staff must not close the Community Services Interest List (CSIL) record for an MDCP MFP applicant.

PSU staff must not:

  • deny MDCP for an MDCP MFP individual; 
  • close the CSIL record for an MDCP MFP individual; or
  • generate and mail Form 2442, Notification of Interest List Release Closure, for an MDCP MFP individual.

PSU staff must refer to Section 6300.9, No Longer Meets the Age Requirement for MDCP, for more information about scenarios where an individual, applicant or member transitions out of MDCP for not meeting the MDCP age requirement.

2414 MDCP Money Follows the Person Delays in NF Discharge

Revision 23-3; Effective May 22, 2023

Program Support Unit (PSU) staff and the managed care organization (MCO) must use their judgment and work with a Medically Dependent Children Program (MDCP) traditional Money Follows the Person (MFP) applicant who has community living arrangements pending but not finalized. 

PSU staff must keep the request for services open if the applicant has an estimated discharge date beyond a four-calendar month period.

PSU staff must refer traditional MFP cases pending beyond four calendar months to the PSU supervisor when an applicant: 

  • has not established living arrangements to return to the community;
  • cannot decide when to return to the community; or 
  • has no viable plan or support system in the community.

2415 Money Follows the Person Demonstration (MFPD) References in STAR Kids

Revision 22-3; Effective Sept. 9, 2022 

Money Follows the Person Demonstration (MFPD) does not apply to the Medically Dependent Children Program (MDCP). Children transition to the least restrictive setting under the traditional Money Follows the Person (MFP) program. For this reason, managed care organizations (MCOs) are not required to track an individual or applicant’s enrollment period or seek informed consent from an individual, applicant, or legally authorized representative (LAR). Program Support Unit (PSU) staff must disregard the "MFPD" check box on Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool. 

2420 Money Follows the Person Limited NF Stay Option for a Medically Fragile Individual

Revision 18-0; Effective September 4, 2018

The limited nursing facility (NF) stay process applies to an individual who requests Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) option, but is too medically fragile to reside in an NF for an extended period of time. Medically fragile is defined as a chronic physical condition that results in a prolonged dependency on medical care. The individual is either already enrolled in STAR Kids or new to the program.

Typically, an individual must meet two or more of the following criteria to be considered medically fragile:

  • ventilator dependent with tracheostomy (not bi-level positive airway pressure (BiPap));
  • renal dialysis;
  • 24 hour/day supplemental oxygen dependence;
  • total nutrition through enteral tube feeding;
  • total parenteral nutrition (TPN);
  • seizures requiring medical intervention (e.g., medication administration, oxygen) during the seizure, every day for the past six months;
  • documented immune deficiency confirmed by lab findings (i.e., immunoglobulin A (IgA) or immunoglobulin G (IgG) deficiency) or on immunosuppressive drug therapy;
  • congestive heart failure requiring hospitalization and routine medication within the past six months; or
  • in hospice care.

An individual determined to be medically fragile and is approved for a limited NF stay, must stay at least part of two consecutive days in the NF. MDCP services must be authorized within 24 hours of discharge to allow for continuity of services and to establish Medicaid in an NF setting. Managed care organization (MCO) service coordinators must stress to the individual, legally authorized representative (LAR) or authorized representative (AR), in order to ensure compliance with MFP limited NF stay policy for continuity of services, an applicant may not discharge from an NF on a Friday, Saturday, Sunday, or any day preceding a state holiday as services must be authorized within 24 hours of discharge. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy. 

2421 Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay

Revision 18-0; Effective September 4, 2018

An individual requesting Medically Dependent Children Program (MDCP) services through the Money Follows the Person (MFP) limited nursing facility (NF) stay option may contact the Interest List Management (ILM) Unit or his or her managed care organization (MCO) service coordinator. If an individual contacts a Texas Health and Human Services Commission (HHSC) regional office, or his or her MCO service coordinator, the individual must be referred to ILM Unit staff to add the individual’s name to the interest list. 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 NF stay option.

ILM Unit staff must explain the following to the individual requesting to bypass the MDCP interest list:

  • STAR Kids program, if not enrolled;
  • an overview of MDCP services;
  • the limited NF stay enrollment process, including that the individual must first be approved for the limited NF stay;
  • the NF may charge the individual a fee for the NF stay, which Medicaid will not reimburse;
  • Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed in its entirety by a physician licensed in the state of Texas by the Texas Medical Board and signed within 90 days of receipt by ILM Unit staff;
  • required medical documentation from the individual’s clinical record at the physician’s office, hospital or clinic (not from a patient portal) must be within 12 months of the date the documentation is submitted to ILM Unit staff; and
  • admission and discharge documentation from the NF will be required.

ILM Unit staff will mail Form 2406 to the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within one business day of the contact, along with a self-addressed stamped envelope to return Form 2406 and required documentation to the ILM Unit staff.

If the individual, parent, guardian, LAR or AR is reapplying after being denied the limited NF stay, ILM Unit staff must inform the individual, parent, guardian, LAR or AR a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered. 

2422 Money Follows the Person Limited Nursing Facility Stay Procedures

Revision 18-0; Effective September 4, 2018 

 

2422.1 Processing Form 2406 and Medical Documents

Revision 18-0; Effective September 4, 2018

Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, must be completed by the individual’s physician, licensed to practice in the state of Texas through the Texas Medical Board, and signed by the physician within 90 days of receipt by Interest List Management (ILM) Unit staff, to be considered for the Money Follows the Person (MFP) limited nursing facility (NF) stay option. The Texas physician must attach to Form 2406 documentation (such as a visit note or hospital discharge summary) of chronic conditions. The medical documentation provided must include:

  • documentation of the individual’s chronic conditions and the current health status of the individual  that will substantiate the boxes checked on Form 2406; and
  • medical records from within 12 months of the date the documentation is being submitted. Medical records must be physician-originated (not from a patient portal).

Upon receipt of Form 2406 and medical documentation, ILM Unit staff will identify the physician’s recommendation.

If the individual’s physician attests the individual does meet the medically fragile criteria and is too medically fragile to reside in an NF setting for an extended period of time on Form 2406, ILM Unit staff will verify the following within two business days:

  • the individual’s name and date of birth are present and legible on Form 2406;
  • the individual is under age 21;
  • the physician’s name, address, license number, signature and date are on Form 2406;
  • physician that signed Form 2406 is licensed in the state of Texas by conducting a license search on the Texas Medical Board’s website; and
  • physician signature on Form 2406 is within 90 days of receipt.

If Form 2406 contains all required information and medical documentation appears to be from an appropriate source and dated within the allowable date range, ILM Unit staff will email all documents to the Texas Health and Human Services Commission (HHSC) nurse to determine if the individual meets the medically fragile criteria. ILM Unit staff must submit each request in a separate email to the HHSC nurse. The email’s subject line must read: Medically Dependent Children Program Form 2406 for XX. The “XX” in the title represents the initials of the individual; therefore, the subject line of an email on behalf of Ann Smith would read "Medically Dependent Children Program Form 2406 for AS."

ILM Unit staff must place the individual in a “Release” status in the Community Services Interest List (CSIL) database using the bypass code “Residing in a Nursing Facility.” ILM Unit staff will also create a Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record and upload Form 2406. ILM Unit staff must not upload medical records to the HEART case record.

If the individual’s physician attests the individual does not meet the medically fragile criteria for a limited NF stay, ILM Unit staff must contact the individual within two business days, to inform him or her of the physician’s recommendation. The individual can remain on the interest list until his or her name reaches the top, or follow the traditional MFP option as described in Section 2410, Traditional Money Follows the Person.

If Form 2406 does not contain the required information, ILM Unit staff must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within two business days of receipt to discuss the elements of the form that are incomplete, and that Form 2406 and associated documents will be returned.

This includes medical documentation that is over 12 months old or not from an appropriate source (such as a patient portal). The individual, parent, guardian, LAR or AR, may submit additional records to satisfy the medical record requirement. If additional records are not submitted before the physician signature on Form 2406 expires (90 days from the physician signature date), the Medically Dependent Children Program (MDCP) MFP limited NF stay interest list request will remain in an “Open” status until the individual reaches the top of the interest list and no additional action is taken. 

2423 HHSC Nurse or Physician Review of Medical Fragility

Revision 18-0; Effective September 4, 2018

A Texas Health and Human Services Commission (HHSC) nurse will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and medical documentation within two business days to determine if an individual meets the limited nursing facility (NF) stay criteria.

If the individual’s physician attests the individual meets the medically fragile criteria and the physician’s documentation clearly substantiates the individual meets two or more criteria on Form 2406, the HHSC nurse may approve the limited NF stay request. Within two business days of the decision, the HHSC nurse will document his or her decision that the individual “meets criteria” in the referral email sent by the Interest List Management (ILM) Unit staff and reply all to notify ILM Unit staff of the decision.

If the documentation does not substantiate the individual meets two or more criteria on Form 2406, the HHSC nurse will forward Form 2406 and associated medical records to the HHSC physician for a decision. ILM Unit staff are also included in the email. 

2424 Physician Determination of Medical Fragility

Revision 18-0; Effective September 4, 2018

The Texas Health and Human Services Commission (HHSC) physician will review Form 2406, Physician Recommendation for Length of Stay in a Nursing Facility, and associated medical records to determine if the individual meets the medically fragile criteria. The HHSC physician will respond by email within seven days to the HHSC nurse with his or her decision. The response will indicate if the individual “meets criteria” or “does not meet criteria.” Within two business days of the decision, the HHSC nurse will document the physician’s decision in the referral email sent by the ILM Unit staff and reply all to notify ILM Unit staff of the decision. 

2425 Individual Not Meeting the Medically Fragile Criteria

Revision 18-0; Effective September 4, 2018

If the Texas Health and Human Services Commission (HHSC) physician determines the individual does not meet the medically fragile criteria, Interest List Management (ILM) Unit staff will contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) by telephone within two business days of receipt of the HHSC physician’s decision email. If the HHSC physician has a comment regarding the information submitted, this will be noted in the HHSC physician response to ILM Unit staff. ILM Unit staff must include this comment when advising the individual of the outcome of the limited nursing facility (NF) stay request. ILM Unit staff will inform the individual that a limited NF stay is not approved and the individual has the option to transition from an NF stay, as described in Section 2410, Traditional Money Follows the Person, to access Medically Dependent Children Program (MDCP) through the Money Follows the Person (MFP) traditional option.

If the individual does not choose to complete an NF stay as described in Section 2410, his or her name will return to an “Open” status in the Community Services Interest List (CSIL) database and the “Residing in a Nursing Facility” bypass code removed. The individual will remain on the interest list until his or her name comes to the top of the list. If the individual, parent, guardian, LAR or AR requests to reapply for the limited NF stay process, ILM Unit staff must inform the individual, parent, guardian, LAR or AR that a new Form 2406 must be submitted if the physician signature is older than 90 days. In addition, medical records not previously submitted must also be obtained or the request will not be considered. 

2426 ILM Unit Procedures for Assigning an Individual Approved for a Limited NF Stay to PSU Staff

Revision 18-0; Effective September 4, 2018

Within two business days of an individual being approved for a limited nursing facility (NF) stay, Interest List Management (ILM) Unit staff must assign the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record to the appropriate Program Support Unit (PSU) staff. No further action is required for ILM Unit staff. 

2427 PSU Procedures for an Individual Approved for a Limited NF Stay

Revision 18-0; Effective September 4, 2018

Within two business days of Program Support Unit (PSU) staff receiving the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment from Interest List Management (ILM) Unit staff, PSU staff must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the individual receives Medicaid. 

2427.1 PSU Procedures for an Individual Approved for a Limited NF Stay without Medicaid (Including an Individual Enrolled in CHIP)

Revision 21-10; Effective October 25, 2021

An individual who does not receive Medicaid and is not enrolled in a managed care organization (MCO) requesting a Money Follows the Person (MFP) limited stay must go through the process of MCO selection, medical necessity (MN) assessment and financial eligibility determination, including individuals enrolled in the Children’s Health Insurance Program (CHIP).

Interest List Management (ILM) Unit staff complete the following activities for individuals who are on the Medically Dependent Children Program (MDCP) interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within five days of the MDCP case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Contact the individual or LAR to:
    • Verify receipt of the enrollment packet;
    • Confirm interest in MDCP;
    • Explain the Medicaid application process;
    • Give a general description of MDCP services;
    • Explain the need to select an MCO as quickly as possible;
    • Inform the individual or LAR that any delay in selecting an MCO could result in a delay in an eligibility determination for MDCP;
    • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
    • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible; and
  • Advise the individual or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS;
  • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200;
  • Ensure the individual or LAR understands the MFP limited stay process by advising the individual that the MFP limited stay:
    • Must be coordinated with the MCO service coordinator;
    • Cannot be completed until notified by the MCO service coordinator;
    • Requires the individual, applicant or LAR to present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the MFP limited stay admission and discharge;
    • Must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
    • Process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual does not have an interest in pursuing MDCP services.

PSU staff must complete the following activities within two business days of the receipt of a completed Form H1200:

  • Check TIERS to verify Medicaid eligibility;
  • Fax the signed and completed Form H1200 and all financial verifications to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, along with Form H1746-A identifying the application is for an MDCP MFP limited stay applicant and eligibility must be expedited and assigned immediately; and
  • Email OESMEPDIC@hhsc.state.tx.us that documents have been faxed to MEPD and advise them to expedite the applicant's eligibility process. The email’s subject line must read: “MDCP Request for Expedited Processing for XXX.XXX.” The “XXX.XXX” in the title represents the first three letters of the applicant’s first and last name. For example, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for ANN.SMI." These assignments will be special assigned by an MEPD complaint resolution specialist. PSU staff must also cc OESCCCIC@hhsc.state.tx.us. The purpose of this email is to advise MEPD:
    • PSU staff have faxed Form H1200 to the MEPD specialist; and
    • to expedite the applicant’s eligibility process since this case is an MFP limited stay case; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual or LAR:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant or LAR:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select an MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited stay without an SK-SAI with an approved MN determination.

PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection and interest in MDCP. PSU staff must assign an MCO based on criteria developed by HHSC from the list of available MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected an MCO within 30 days from the enrollment packet mail date.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes an MCO selection or from the date they are defaulted to an MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual, applicant or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU staff have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual, applicant or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual, applicant or LAR:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200; and
  • Advise the individual, applicant or LAR to immediately submit Form H1200 if PSU staff do not see Form H1200 in TIERS.

PSU staff must refer to Section 2428, PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay, for PSU and MCO coordination for MFP limited stay applicants. 

2427.2 PSU Procedures for an Individual Approved for a Limited NF Stay with Medicaid and Not Enrolled in STAR Kids

Revision 21-10; Effective October 25, 2021

An individual with Medicaid who is not enrolled in a STAR Kids managed care organization (MCO) requesting a Money Follows the Person (MFP) limited stay must go through the process of STAR Kids MCO selection, medical necessity (MN) assessment and financial eligibility determination, if applicable.

Interest List Management (ILM) Unit staff complete the following activities for individuals who are on the Medically Dependent Children Program (MDCP) interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART);
  • Verify the individual is on the interest list for MDCP in the Community Services Interest List (CSIL) database;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to Program Support Unit (PSU) staff.

ILM Unit staff complete the following activities for individuals who are not on the MDCP interest list and request to pursue the MFP limited stay process:

  • Create an MDCP case record assignment in HEART;
  • Confirm the individual is not on the interest list in the CSIL database;
  • Add the individual to the interest list;
  • Immediately release the individual from the interest list using the bypass code “Residing in a Nursing Facility”; and
  • Assign the MDCP case record assignment in HEART to PSU staff.

PSU staff must complete the following activities within five days of the MDCP case record assignment in HEART:

  • Check the Texas Integrated Eligibility Redesign System (TIERS) to verify Medicaid financial eligibility;
  • Refer to Appendix XVI, Medicaid Program Actions, to determine if the individual requires Form H1200, Application for Assistance – Your Texas Benefits, and Form H1746-A, MEPD Referral Cover Sheet, to determine financial eligibility for MDCP;
  • Ensure that the individual does not have an open enrollment with another Medicaid waiver program according to the procedures below:
    • for either the Texas Home Living (TxHmL) or Home and Community-based Services (HCS) waiver programs, check the Client Assignment and Registration (CARE) System, Screen 397 series, Client ID Information Screens, to verify whether the individual is enrolled in one of these programs. The screen specific to "waiver consumer assignment history" identifies enrollment, when applicable;
    • for the Community Living Assistance and Support Services (CLASS) (Service Group 2) and Deaf Blind with Multiple Disabilities (DBMD) (Service Group 16) waiver programs, check the Service Authorization System Online (SASO) to verify the service authorization record for these waiver programs; and
    • review the TIERS Long Term Services and Supports (LTSS) screen; and
  • Mail the following enrollment packet to the individual or legally authorized representative (LAR):
  • Contact the individual or LAR to:
    • Verify receipt of the enrollment packet;
    • Confirm interest in MDCP;
    • Explain the Medicaid application process, if applicable;
    • Give a general description of MDCP services;
    • Explain the need to select a STAR Kids MCO as quickly as possible;
    • Inform the individual or LAR that any delay in selecting a STAR Kids MCO could result in a delay in an eligibility determination for MDCP services;
    • Encourage the individual or LAR to complete the enrollment packet and mail it back to the Texas Health and Human Services Commission (HHSC) as quickly as possible, if the individual:
      • has not selected a STAR Kids MCO;
      • has not expressed interest in MDCP; or
      • has not provided Form H1200, if applicable; and
    • Inform the individual or LAR a request to change their MCO can be made at any time but the effective date for the change may be the next month or the following month depending on when the change request is received;
    • Advise the individual or LAR to immediately submit Form H1200 if:
      • the individual requires Form H1200 to determine Medicaid financial eligibility; and
      • PSU staff do not see Form H1200 in TIERS;
    • Confirm Form H1200 appears in TIERS if the individual or LAR informs PSU staff that they have completed and submitted Form H1200, if applicable; and
    • Ensure the individual or LAR understands the MFP limited stay process by advising the individual that the MFP limited stay:
      • must be coordinated with the MCO service coordinator;
      • cannot be completed until notified by the MCO service coordinator;
      • requires the individual, applicant or LAR to present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the MFP limited stay admission and discharge;
      • must not occur on a Friday, Saturday, Sunday or any other day preceding a state holiday; and
      • process requires that MDCP be authorized by PSU staff within 24 hours of the nursing facility discharge.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must refer to Section 2120, Inability to Contact the Individual, when unable to contact the individual or LAR within 14 days of the enrollment packet mail date.

PSU staff must refer to Section 2130, Declining Medically Dependent Children Program Services, for notification requirements when an individual does not have an interest in pursuing MDCP services.

PSU staff must complete the following activities within two business days of the receipt of a completed Form H1200, if appropriate:

  • Check TIERS to verify Medicaid eligibility;
  • Fax the signed and completed Form H1200, if available, and all financial verifications to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, along with Form H1746-A, identifying the application is for an MDCP MFP limited stay applicant and eligibility must be expedited and assigned immediately; and
  • Email OESMEPDIC@hhsc.state.tx.us that documents have been faxed to MEPD and advise them to expedite the applicant's eligibility process. The email’s subject line must read: “MDCP Request for Expedited Processing for XXX.XXX.” The “XXX.XXX” in the title represents the first three letters of the applicant’s first and last name. For example, the subject line of an email on behalf of Ann Smith would read "MDCP Request for Expedited Processing for ANN.SMI." These assignments will be special assigned by an MEPD complaint resolution specialist. PSU staff must also cc OESCCCIC@hhsc.state.tx.us. The purpose of this email is to advise MEPD:
    • PSU staff have faxed Form H1200 to the MEPD specialist; and
    • to expedite the applicant’s eligibility process since this case is an MFP limited stay case; and
  • Upload all applicable documents to the HEART case record following the instructions in Appendix XVIII, STAR Kids HEART Naming Conventions.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the individual or LAR:

  • Manually generate Form 2442, Notification of Interest List Release Closure;
  • Mail Form 2442 and Appendix XX to the individual or LAR;
  • Upload Form H2067-MC, Managed Care Communication, to TxMedCentral following the instructions in Appendix IX, STAR Kids TxMedCentral Naming Conventions, notifying the MCO that the individual is not eligible for MDCP;
  • Close the interest list release (ILR) in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART record.

PSU staff must complete the following activities if Form H1200 is not received within 45 days of the date PSU staff sent Form H1200 to the applicant, if applicable:

  • Manually generate Form H2065-D, Notification of Managed Care Program Services;
  • Mail Form H2065-D to the applicant or LAR;
  • Upload Form H2065-D to TxMedCentral, following the instructions in Appendix IX;
  • Close the ILR in the CSIL database using the appropriate closure reason and date;
  • Document the closure date, the reason for closure and that Form H1200 was not received within 45 days in the HEART case record;
  • Upload all applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document and close the HEART case record.

The individual, applicant or LAR must select a STAR Kids MCO in order for the MCO to perform the STAR Kids Screening and Assessment Instrument (SK-SAI). PSU staff cannot process the MFP limited stay without an SK-SAI with an approved MN determination.

PSU staff can accept the individual’s, applicant’s or LAR’s verbal statement of an MCO selection or interest in MDCP. PSU staff must assign a STAR Kids MCO based on criteria developed by HHSC from the list of available STAR Kids MCOs in the individual or applicant’s service area (SA) if the individual, applicant or LAR:

  • Has expressed an interest in applying for MDCP; and
  • Has not selected a STAR Kids MCO within 30 days from the enrollment packet mail date.

PSU staff must document all attempted contacts and any delays in the HEART case record.

PSU staff must complete the following activities within two business days from the date the individual, applicant or LAR makes a STAR Kids MCO selection or from the date they are defaulted to a STAR Kids MCO:

  • Complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, Section A;
  • Upload Form H3676, Section A, to TxMedCentral, following the instructions in Appendix IX;
  • Upload applicable documents to the HEART case record, following the instructions in Appendix XVIII; and
  • Document the HEART case record.

PSU staff must contact the individual, applicant or LAR within two business days of the receipt of an enrollment packet that is incomplete, incorrect or missing information to:

  • Obtain a STAR Kids MCO selection if PSU staff have not received the STAR Kids MCO selection;
  • Obtain confirmed interest in MDCP, if PSU have not received confirmation of interest in MDCP;
  • Obtain missing or corrected information required to process the case, if information is missing or incorrect;
  • Encourage the individual, applicant or LAR to complete the enrollment packet and mail it back to HHSC as quickly as possible, if the individual, applicant or LAR:
    • has not selected a STAR Kids MCO;
    • has not expressed interest in MDCP; or
    • has not provided Form H1200, if applicable; and
  • Advise the individual, applicant or LAR to immediately submit Form H1200, if:
    • the individual or applicant requires Form H1200 to determine Medicaid financial eligibility; and
    • PSU staff do not see Form H1200 in TIERS.

PSU must document all contact attempts in the HEART case record.

PSU staff must refer to Section 2428, PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay, for PSU and MCO coordination for MFP limited stay applicants. 

2427.3 PSU Procedures for an Individual Approved for a Limited NF Stay and Currently Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

When an individual who is enrolled in STAR Kids is approved for a limited nursing facility (NF) stay as outlined in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay, within two business days of Program Support Unit (PSU) staff assignment, PSU staff must complete Form H3676, Managed Care Pre-Enrollment Assessment Authorization, indicating the applicant is a Supplemental Security Income (SSI) Money Follows the Person (MFP) individual. PSU staff also complete Section A of Form H3676 stating the member resides at home. In the comments section, indicate this is a STAR Kids member approved for the Medically Dependent Children Program (MDCP) MFP limited NF stay option and post Form H3676 to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

Within five days of the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record assignment, PSU staff must contact the applicant, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) to ensure the applicant understands the limited NF stay must be coordinated with his or her managed care organization (MCO) service coordinator and cannot be completed until he or she is notified by the service coordinator. 

2428 PSU and MCO Staff Coordination Procedures for an MDCP Applicant Approved for a Limited NF Stay

Revision 18-0; Effective September 4, 2018

When an individual is approved for a limited nursing facility (NF) stay, the managed care organization (MCO) service coordinator must contact the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) within 14 days from the date the MCO receives Form H3676, Managed Care Pre-Enrollment Assessment Authorization, in TxMedCentral advising the MCO of the decision to complete a limited NF stay. The STAR Kids Uniform Managed Care Contract (UMCC) requires the MCO to initiate contact with an applicant to begin the assessment process within 14 days of receipt of Form H3676.

At the contact, the MCO informs the individual, parent, guardian, LAR or AR of the Medically Dependent Children Program (MDCP) eligibility process. The MCO explains the limited NF stay, and the individual must present Form 3618, Resident Transaction Notice, to the MCO service coordinator showing the time and date of the limited NF stay admission and discharge. Form 3618 must be received by the MCO and posted to TxMedCentral by the MCO the same date as the NF discharge or MDCP services cannot be authorized. The MCO must explain the NF may charge a fee for the limited NF stay that will not be reimbursed by Medicaid or the MCO. The MCO must explain the individual must not proceed with the limited NF stay until he or she is authorized to do so by the MCO. MDCP services must be authorized within 24 hours of the NF discharge date to meet Money Follows the Person (MFP) limited NF stay funding requirements. MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. MCO service coordinators must ensure Form 3618 is posted to TxMedCentral for Program Support Unit (PSU) staff to access the same day of NF discharge. Form 3618 is the only instrument accepted to verify the appropriate NF admission and discharge requirement. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy and MDCP services will not be authorized.

The MCO has 60 days to complete all assessments and submit required forms to PSU staff. The MCO must complete:

  • Section B of Form H3676, noting "MFP Limited NF Stay Assessment Completed" in the comments section;
  • the STAR Kids Screening and Assessment Instrument (SK-SAI), including Section R, MDCP Related Items;
  • the electronic Form 2604, Individual Service Plan - Service Tracking Tool; and
  • Form 2603, STAR Kids Individual Service Plan (ISP) Narrative.

The MCO must post Form H3676 to TxMedCentral in the MCO STAR Kids folder and submit the electronic Form 2604 in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. If the applicant is medical assistance only (MAO) and does not have a Medicaid identification (ID) number at the time the MCO is attempting to upload Form 2604 into the TMHP LTC Online Portal, the MCO uses “+” in the designated field for Medicaid ID. Once the applicant has been authorized for MDCP services for 30 days, a Medicaid ID number will be assigned to the individual and the Texas Integrated Eligibility Redesign System (TIERS) will update the TMHP LTC Online Portal. Refer to Appendix I, MCO Business Rules for SK-SAI and SK-ISP, for additional information. The MCO must maintain a copy of Form 2603 in the applicant’s or member’s MCO case file.

If the MCO does not submit an ISP in the TMHP LTC Online Portal within 60 days after PSU staff posted Form H3676, Section A, PSU staff notify Managed Care Compliance & Operations by email indicating the MCO delinquency in performing the assessment.

Within two business days of receiving Form H3676 in TxMedCentral and Form 2604 in the TMHP LTC Online Portal, PSU staff verify the member:

  • is under age 21 in TIERS;
  • is a Texas resident in TIERS;
  • has an approved MN in the TMHP LTC Online Portal;
  • has ongoing financial eligibility in TIERS or by an email through the Medicaid for the Elderly and People with Disabilities (MEPD) Communication Tool stating Medicaid is approved pending the limited NF stay and 30 days of MDCP authorization;
  • has an ISP within the individual’s cost limit; and
  • has authorization of at least one MDCP service on the ISP.

For STAR Kids members accessing MDCP through the limited NF stay process, if the above criteria are met except for the limited NF stay, PSU staff post Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions,  to notify the MCO of the MDCP approval pending completion of the limited NF stay.

For applicants not receiving Medicaid, and since Medicaid will not be established until 30 days after the applicant completes the limited NF stay and MDCP authorization, PSU staff can approve the individual to move forward to complete the limited NF stay as long as all other eligibility criteria are met and MEPD has communicated to PSU staff that the individual is eligible for Medicaid except for the NF stay and 30 days of MDCP authorization. PSU staff post Form H2067-MC to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, to notify the MCO to proceed with the limited NF stay. The MCO service coordinator must notify PSU staff within five business days of the planned NF discharge date by posting Form H2067-MC to TxMedCentral, following the instructions in Appendix IX.

The MCO service coordinator must coordinate the limited NF stay with the MDCP applicant, parent, guardian, LAR, AR, NF staff and PSU staff. Form 3618 must be completed by the NF and submitted to the MCO service coordinator within 24 hours of the time of discharge. The NF must understand the importance of processing and providing Form 3618 to the family and/or MCO service coordinator prior to NF discharge.

MCO service coordinators must ensure an applicant does not discharge from the NF on a Friday, Saturday, Sunday, or any day preceding a state holiday to remain in compliance with MFP limited NF stay policy for continuity of services. If MDCP services cannot be authorized within 24 hours after the NF discharge date, the NF stay will not be accepted as meeting MFP limited NF stay policy and MDCP services will not be authorized.

Within 24 hours of the limited NF stay, the following activities must occur:

  • the MCO must notify PSU staff the limited NF stay occurred by posting Form H2067-MC in TxMedCentral, following the instructions in Appendix IX, requesting PSU staff approve MDCP services;
  • the MCO must post Form 3618 to TxMedCentral in the MCO’s STAR Kids folder;
  • PSU staff must respond to the MCO on Form H2065-D, Notification of Managed Care Program Services, by posting to TxMedCentral in the MCO’s STAR Kids folder, following the instructions in Appendix IX, noting the applicant or member is pending approval of Medicaid eligibility; however, the applicant or member is eligible for MDCP services and the MCO must send an authorization to the selected provider to begin services; and
  • PSU staff upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Record Tracking System (HEART) case record.

Once the MCO notifies PSU staff that the applicant is authorized to receive MDCP services, within two business days, PSU staff must:

  • complete and mail the original Form H2065-D to the member, LAR or AR;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record;
  • fax Form H2065-D and Form H1746-A, MEPD Referral Cover Sheet, to the MEPD specialist, indicating the individual has transferred from an NF to the MDCP, if applicable;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, if Form H2065-D was manually completed;
  • email Enrollment Resolution Services (ERS), if applicable, with the following:
    • the individual’s name;
    • Medicaid identification (ID) number;
    • type of request (MFP limited stay);
    • date of MFP limited NF stay;
    • MN approval date;
    • ISP receipt date;
    • ISP begin date;
    • ISP end date;
    • MCO selection;
    • effective date of enrollment;
    • Form H2065-D; and
  • upload all applicable documents in HEART case record.

The MDCP effective date will be the first of the month in which the MFP individual was discharged from the NF.

Example: An individual who is not enrolled in STAR Kids leaves the NF December 12, 2016, and begins MDCP services December 12, 2016. The eligibility date on Form H2065-D will be December 1, 2016.

After the individual has been determined eligible for MDCP, ERS updates the individual’s Texas Integrated Eligibility and Redesign System (TIERS) record to indicate managed care enrollment, if applicable.

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

If the individual fails to meet any of the eligibility criteria for MDCP or Medicaid is denied by the MEPD specialist for financial eligibility, the MCO must post within two business days of receiving Form H3676 and Form H2067-MC, notifying PSU staff of the program denial. PSU staff must:

  • manually complete Form H2065-D;
  • mail the final Form H2065-D to the individual;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • fax Form H2065-D and Form H1746-A to the MEPD specialist, if applicable;
  • email Enrollment Resolution Services (ERS), if applicable;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload all applicable documents to the HEART case record.

The MCO must monitor the TMHP LTC Online Portal to retrieve the final Form H2065-D. 

2429 Delays in Limited NF Stay for an Applicant Not Enrolled in STAR Kids

Revision 18-0; Effective September 4, 2018

If there is a delay in the nursing facility (NF) stay, the managed care organization (MCO) must notify Program Support Unit (PSU) staff by posting Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX, Naming Conventions.

If the NF stay cannot be completed within 40 days after the date Form H1200, Application for Assistance - Your Texas Benefits, was submitted to Medicaid for the Elderly and People with Disabilities (MEPD) specialist, PSU staff must request the MEPD specialist to delay Medicaid certification. PSU staff document the request for a delay in certification on Form H1746-A, MEPD Referral Cover Sheet, and fax Form H1746-A to the MEPD specialist. Form H1746-A must be uploaded to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff should include the following statement in the comments section of Form H1746-A: “Request for delay in certification due to delay in NF stay; start date of MDCP services is pending.” If approved, the delay request will extend the MEPD specialist time frame to 135 days from the original file date or 180 days from the original file date if a disability determination is required. If there is a continued delay in completion of the NF stay beyond 135 days from the file date or 180 days from the file date for an applicant requiring a disability determination, the MEPD specialist will deny the application. Once PSU staff confirm the Medicaid denial, PSU staff must deny Medically Dependent Children Program (MDCP) eligibility by:

  • manually completing Form H2065-D, Notification of Managed Care Program Services;
  • mail the original Form H2065-D to the applicant or member;
  • post Form H2065-D to TxMedCentral in the MCO STAR Kids folder, following the instructions in Appendix IX;
  • fax Form H2065-D and Form H1746-A to the MEPD specialist;
  • document the closure date and reason in the Community Services Interest List (CSIL) database and close the record; and
  • upload Form H2065-D and all other applicable documents to the HEART case record and close the HEART case record.

MCOs must monitor the TMHP LTC Online Portal for the status of their member’s individual service plan (ISP) and to retrieve Form H2065-D.

If the individual, parent, guardian, legally authorized representative (LAR) or authorized representative (AR) chooses to continue to pursue the Money Follows the Person (MFP) limited NF stay option after program eligibility has been denied, the MFP limited NF stay application process must start over. To begin the process again, the individual may re-apply by contacting ILM Unit staff, as described in Section 2421, Money Follows the Person Procedures for Requesting a Limited Nursing Facility Stay.

If the applicant’s medical necessity (MN) has expired due to the delay in the NF stay, the MCO must complete a new STAR Kids Screening and Assessment Instrument (SK-SAI). If the SK-SAI is completed within 90 days of the MEPD specialist’s denial, PSU staff may request the MCO obtain a letter signed by the individual, parent, guardian, LAR or AR requesting to reopen the Medicaid application. The MCO must post the letter on TxMedCentral in the MCO STAR Kids folder. PSU staff must fax the letter with Form H1746-A marked “Application” to the MEPD specialist within two business days. The MEPD specialist’s time frame for certification will start over. If the NF stay cannot be completed within 40 days after the date of the request to reopen the Medicaid application was submitted to the MEPD specialist, PSU staff must request the MEPD specialist delay certification. However, the MEPD specialist may not approve additional requests for delay in certification based on the amount of time that has passed since the original application file date.

If the MEPD specialist approves the request for delay in certification, PSU staff must notify the MCO to proceed with coordination of the NF stay and enrollment procedures by posting Form H2067-MC in TxMedCentral, following the instructions in Appendix IX. If the MEPD specialist denies the request to delay certification due to the age of the application, PSU staff must inform the individual, parent, guardian, LAR or AR that a new Form H1200 must be completed.