3200, Member Reassessment

Revision 18-0; Effective September 4, 2018

All STAR Kids members are reassessed using the STAR Kids Screening and Assessment Instrument (SK-SAI) at least annually. The managed care organization (MCO) is responsible for tracking the renewal dates to ensure all member reassessment activities are completed no later than 30 days prior to the end of the individual service plan (ISP). Failure to complete and submit timely reassessments may result in the member losing Medically Dependent Children Program (MDCP) or Medicaid eligibility. Before the end date of the annual SK-SAI, the MCO must initiate a reassessment to determine and validate continued need for services for each member. The MCO may not conduct the SK-SAI earlier than 90 days prior to the end of the ISP. For members in MDCP or receiving Community First Choice (CFC) services, reassessment must occur no later than 30 days prior to the end date of the current individual service plan (ISP) on file. As part of the assessment, the MCO must inform the member about the Consumer Directed Services (CDS) option and Service Responsibility Option (SRO). The MCO is expected to complete the same activities for each annual assessment as required for the initial eligibility determination.

If the MCO determines the member’s health and support needs have not changed significantly within a calendar year of completing the SK-SAI based on utilization records, member reports and provider input, the MCO may administer an abbreviated version of the SK-SAI by pre-populating the instrument with information gathered during the previous assessment and confirming the accuracy of information with the member, legally authorized representative (LAR) or authorized representative (AR). The MCO may not administer the abbreviated SK-SAI more than once every other calendar year and may not administer the abbreviated SK-SAI without previously completing the full SK-SAI.

For members who receive Personal Care Services (PCS), the MCO must include the personal care assessment module (PCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The PCAM must also be completed at any time the MCO determines the member may require a change in the number of authorized PCS hours, such as a change of condition or change in available informal supports (e.g., changing school schedules). For members who receive nursing services, the MCO must include the nursing care assessment module (NCAM) as part of the annual SK-SAI and as requested by the member, LAR or AR. The MCO must also complete the NCAM at any time the member may require a change in the number of authorized hours of nursing services, such as a change in condition.

3210 Medically Dependent Children Program Eligibility

Revision 22-3; Effective Sept. 9, 2022 

A 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 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.

3210.1 Texas Administrative Code Medically Dependent Children Program Eligibility Requirements

Revision 22-3; Effective Sept. 9, 2022 

A 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: 
  • 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).

3210.2 Reassessment of Medical Necessity Determination

Revision 23-4; Effective Aug. 21, 2023

A Medically Dependent Children Program (MDCP) member must have a valid medical necessity (MN) determination for a nursing facility (NF) level of care (LOC) before Program Support Unit (PSU) staff recertifies the member for MDCP. The MN determination is based on a completed STAR Kids Screening and Assessment Instrument (SK-SAI).

The managed care organization (MCO) is not required to get a physician’s signature on Form 2601, Physician’s Certification, for reassessments.

The MCO completes and submits the SK-SAI to the Texas Medicaid & Healthcare Partnership (TMHP) through the TMHP Long Term Care Online Portal (LTCOP) annually. The TMHP nurse or physician processes the SK-SAI and redetermines the member’s Resource Utilization Group (RUG) value and MN.

PSU staff must monitor the TMHP LTCOP every five business days until the MN status updates to one of the final statuses below:

  • MN Approved: The status may change to "MN Approved" if the TMHP physician overturns the denial because more information is received; or 
  • Overturn Doctor Review Expired: The status may change to "Overturn Doctor Review Expired" when the 14-business day period for the TMHP physician to overturn the denied MN has expired, and no additional or inadequate information was submitted for the doctor review. The denied MN remains in this status unless the member, legally authorized representative (LAR), or medical consenter requests a state fair hearing.

Refer to Section 7000, Applicant or Member Appeal Requests and State Fair Hearings, for more information about state fair hearings regarding MN denials.

The MCO must notify PSU staff of a member’s MN denial and request Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to TxMedCentral. Refer to Section 6000, Denials and Terminations, for more information about processing MN terminations. Refer to Section 3328, Reassessment Notification Requirements, for more information about PSU notification requirements.

Refer to the Uniform Managed Care Manual (UMCM) Section 16.2 for specific requirements about the termination of MDCP for STAR Health members.

The MCO uses the SK-SAI to create the member’s reassessment STAR Kids individual service plan (SK-ISP). The SK-ISP lists the member’s services and preferences for care. 

PSU staff do not calculate the SK-ISP cost limit. TMHP LTCOP automatically calculates the cost limit based on the RUG value. PSU staff must verify the member’s SK-ISP is within the cost limit by verifying the Total Estimated Waiver Costs is less than the Annual Cost Limit in the TMHP LTCOP SK-ISP.

The MCO must:

  • Track the SK-SAI and SK-ISP renewal dates to ensure all member reassessment activities are completed within 30 days before the SK-ISP expiration date. 
  • Not conduct the SK-SAI earlier than 90 days before the one-year anniversary of the previous SK-SAI. 
  • Submit the SK-SAI in the TMHP LTCOP no earlier than 90 days before or no later than 30 days before the expiration of the member’s current SK-ISP on file. 
  • Upload Form H2067-MC to TxMedCentral documenting any reason for a delay.

The assigned PSU staff must notify Program Support Operations Review Team (PSORT) of late MCO reassessment activity by sending the ISP Expiring Report to the PSORT mailbox monthly. The ISP Expiring Report details members with SK-ISPs that expire within the next 90 days. The ISP Expiring Report must be in an Excel spreadsheet format. The assigned PSU staff must edit the ISP Expiring Report so that it only identifies SK-ISPs reported as an MCO non-compliance. The subject line for the email must read: “MDCP Reassessment Delinquencies for [Month]”.

PSU staff are not required to send a follow-up email to PSORT when the MCO submits the following documents for reassessment delinquencies: 

  • Form H2067-MC; 
  • the SK-SAI; or 
  • the SK-ISP.

Refer to Section 3327.1, Process for Reviewing the Individual Service Plan Expiring Report, for more information about the ISP Expiring Report.

PSU staff must upload all applicable documents to the Texas Health and Human Services (HHS) Enterprise Administrative Report and Tracking System (HEART) case record. PSU staff must document the HEART case record.
 

3210.3 Texas Administrative Code Medical Necessity Determination Requirements

Revision 22-3; Effective Sept. 9, 2022 

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

  • The individual must demonstrate a medical condition that: 
    • is sufficient serious that the individual's needs exceed the routine care which may be given by an untrained person; and 
    • requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution. 
  • The individual must require medical or nursing services that: 
    • a physician orders; 
    • are dependent upon the individual's documented medical conditions; 
    • require the skills of a registered or licensed vocational nurse; 
    • are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and 
    • are required on a regular basis.

PSU staff must refer to Section 3210.2, Reassessment of Medical Necessity Determination, for the information about MN redetermination procedures.