Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language

Revision 24-4; Effective Dec. 1, 2024

Program Support Unit (PSU) staff must use Appendix II, Form H2065-D MDCP Reason for Denial and Comments Language, to enter approved language in the Reason for Denial and Comments fields on Form H2065-D, Notification of Managed Care Program Services (PDF), and Form H2065-DS. PSU staff must not enter additional language in the Reason for Denial or Comments fields of Form H2065-D or Form H2065-DS. PSU staff must consult with their supervisor if they encounter a denial reason or comment not covered in Appendix II.

Reason for Denial and Comments language is illustrated in both English and Spanish in the tables below.

PSU staff must enter the denial reason in the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP) associated with the denial reason on Form H2065-D and Form H2065-DS. The denial reason in the TMHP LTCOP associated with the denial reason on Form H2065-D and Form H2065-DS is listed in the TMHP Denial Reason column in the table below.

Denial and Termination Reason Language

The table below has language PSU staff must enter in the Reason for Denial and Comments field on Form H2065-D and Form H2065-DS for denials and terminations.

PSU staff must enter the associated STAR Kids Program Support Unit Operational Procedures Handbook (SKOPH) section supporting the denial reason on Form H2065-D and Form H2065-DS, listed in the SKOPH Section column.

Purpose of Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSKOPH SectionTMHP Denial Reason
Unable to Locate

You are not eligible for MDCP because HHSC staff or your health plan cannot locate you to complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque la HHSC o su plan médico no lo han podido localizar para que se someta a la valoración que requiere el programa.

PSU staff must not enter comments language.6300.6Applicant/Member whereabouts are unknown
Voluntarily Declined Services

You are not eligible for MDCP because you voluntarily withdrew from the program.

Usted no puede recibir servicios del MDCP porque abandonó voluntariamente el programa.

PSU staff must not enter comments language.6300.3

Applicant: Applicant requested application for services be closed

Member: Member requests service termination

Enrolled in Another 1915(c) Medicaid Waiver

You are not eligible for MDCP. This is because you are enrolled in another Medicaid waiver program. You can only be enrolled in one Medicaid waiver program at a time.

Usted no reúne los requisitos para el programa MDCP. Esto se debe a que usted está inscrito en otro programa con exenciones de Medicaid. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez.

You are not eligible for MDCP. This is because you are currently enrolled in [Select one: Community Living Assistance and Support Services (CLASS); Deaf Blind with Multiple Disabilities (DBMD); Home and Community-based Services (HCS); Texas Home Living (TxHmL)]. MDCP cannot be authorized. You can only be enrolled in one Medicaid waiver program at a time.

Usted no reúne los requisitos para el programa MDCP. Esto se debe a que usted está inscrito actualmente en [Select one: Programa de Servicios de Apoyo y Asistencia para Vivir en la Comunidad (CLASS); Programa para Personas Sordociegas con Discapacidades Múltiples (DBMD); Programa de Servicios en el Hogar y en la Comunidad (HCS); Programa de Texas para Vivir en Casa (TxHmL)]. No se puede autorizar el programa MDCP. Solo puede estar inscrito en uno de los programas con exenciones de Medicaid a la vez.

6110Applicant/Member can only be enrolled in one 1915(c) waiver program at a time
Financial Eligibility

You are not eligible for MDCP because you do not meet the financial criteria necessary for the program.

Usted no puede recibir servicios del MDCP porque no cumple los criterios financieros necesarios para participar en el programa.

Call 2-1-1 if you have questions about the Medicaid application process.

Llame al 2-1-1 si tiene preguntas sobre el proceso de solicitud de Medicaid.

6300.4Applicant/Member denied Medicaid eligibility
Declined Assessment

You are not eligible for MDCP because you did not let your health plan complete the assessment required for the program.

Usted no puede recibir servicios del MDCP porque no permitió que el plan médico realizara la valoración que requiere el programa.

PSU staff must not enter comments language.6110Applicant/Member failure to provide information
Living Arrangement is Not an Allowable Setting

You are not eligible for MDCP because where you live is not an allowable setting to receive services. Code of Federal Regulations at Title 42 CFR Section 441.301(c)(5) describes these settings.

Usted no puede recibir beneficios de MDCP porque donde vive no es un entorno adecuado para recibir servicios. Estos servicios están descritos en la sección 441.301(c)(5) del título 42 del Código de Reglamentos Federales (CFR).

PSU staff must not enter comments language.6300.2Applicant/Member does not reside in an allowable living arrangement
Does Not Have an Unmet Need

You are not eligible for MDCP because you do not need services offered through the program.

Usted no puede recibir los servicios del MDCP porque no los necesita.

PSU staff must not enter comments language.6110Applicant and Member: Need for at least one waiver service per individual service plan year
Failure to Obtain Physician's Signature

You aren't eligible for MDCP because your doctor didn't tell us you need the level of care provided in a nursing home.

Usted no puede recibir los servicios del MDCP porque su médico no nos informó que usted necesita el nivel de atención que se ofrece en una casa de reposo.

PSU staff must not enter comments language.6300.8Applicant/Member failure to provide information
Medical Necessity and Level of CareReason for denial language must be populated through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTOCP).

You are not eligible for MDCP. See the Reason for Denial text box on page 1 of this form and the MDCP Medical Necessity Denial Attachment for more information.

Usted no puede recibir servicios del MDCP. Para más información, vea el cuadro “Motivo de la denegación”, en la página 3 de este formulario, y el anexo “Medical Necessity Denial” (denegación por no existir una necesidad médica) del MDCP.

6300.5Applicant and Member: Denied Medical necessity/level of care
Exceeding the ISP Cost Limit

You are not eligible for MDCP because the cost of your individual service plan exceeds the maximum amount allowed.

Usted no puede recibir servicios del MDCP porque el costo de su plan individual de servicios excede la cantidad máxima permitida.

PSU staff must not enter comments language.6300.7Applicant and Member: Exceeds cost limit
MFP Services Not Authorized Within 24 Hours

You are not eligible for MDCP because services were not authorized within 24 hours of the nursing facility stay.

Usted no puede recibir servicios del MDCP porque los servicios no se autorizaron en las 24 horas siguientes a su estancia en el centro de reposo.

PSU staff must not enter comments language.2428Applicant: PSU staff must contact their supervisor for the appropriate TMHP denial reason.
MFP NF Discharge Prior to Eligibility Determination

You are not eligible for the MDCP because you left the nursing facility before HHSC could determine program eligibility.

Usted no reúne los requisitos para recibir servicios del MDCP porque abandonó el centro de reposo antes de que la HHSC pudiera determinar si reunía los requisitos del programa.

PSU staff must not enter comments language.2001Applicant: Failure to Follow Service Plan
Institutional Stay Over 90 Days

You are not eligible for MDCP because you have entered an institution for a long-term stay, as described in the Code of Federal Regulations (CFR) at Title 42 CFR Section 441.301(b)(1).

Usted no puede recibir servicios del MDCP porque ha ingresado en una institución donde tendrá una estancia a largo plazo, como se describe en la sección 441.301(b)(1) del título 42 del Código de Reglamentos Federales (CFR).

You are not eligible for MDCP services while an in-patient of a [Select one: hospital; nursing facility; intermediate care facility for persons with intellectual disability].

Usted no puede recibir servicios del MDCP mientras sea un paciente interno de [Select one: un hospital; un centro de reposo; un centro de atención intermedia para personas con discapacidad intelectual].

6300.2Applicant and Member: Institutional stay
Moved Out of State

You are not eligible for MDCP because you are not a Texas resident.

Usted no puede recibir servicios del MDCP porque no reside en Texas.

PSU staff must not enter comments language.6110Applicant/ Member: Member moved out of state

Over Age 20 and:

  • Member declines another Medicaid waiver; or 
  • Ages out before eligibility is established for another Medicaid waiver 

You are not eligible for MDCP because you are 21 or older.

Usted no puede recibir servicios del MDCP porque es mayor de 21 años.

PSU staff must not enter comments language.6300.9Applicant/Member must be age 20 years or younger to be eligible for MDCP services
Over Age 20 and Member Transitions to Another Medicaid Waiver

You are not eligible for MDCP because you are 21 or older.

Usted no puede recibir servicios del MDCP porque es mayor de 21 años.

PSU staff must not enter comments language.6300.9Member: Transition to an adult Program
OtherPSU staff must contact supervisor.PSU staff must contact supervisor.PSU staff must contact supervisor.Applicant/Member: PSU staff must contact their supervisor for the appropriate TMHP denial reason.

Approval Language

The table below contains language PSU staff must enter in the Comments field on Form H2065-D and Form H2065-DS for approvals. 

Purpose of Form H2065-DReason for Denial in Plain LanguageComments in Plain LanguageSKOPH SectionTMHP Denial Reason
Medicaid Eligibility Reinstated within Six MonthsNo reason for denial language should be added.

Your Medicaid was reinstated on [DATE]. Your MDCP services will continue without interruption.

Su participación en el programa Medicaid fue restablecida el [DATE]. Usted seguirá recibiendo servicios del MDCP sin interrupción.

N/AN/A
Initial Form H2065-D for MFP to CommunityN/A

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive a second Form H2065-D telling you when your services will begin.

Ud. cumple los requisitos del MDCP. Sus servicios no empezarán hasta que usted y su plan médico acuerden una fecha para su salida de la casa de reposo. Permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén vigentes cuando salga de la casa de reposo. Usted recibirá un segundo Formulario H2065-D en el que se le informará cuándo comenzarán sus servicios.

N/AN/A
Initial Form H2065-D for MFP to ALFN/A

You’re eligible for MDCP. Your services won’t start until you and your health plan agree on a date for you to leave your nursing home. Please stay in the nursing home until you have agreed with your medical plan on a date to leave. This will make sure services are in place when you leave the nursing home. You will receive another notice telling you when your MDCP services will begin. We will also send you a notice telling you how much your room and board and copayment will be.

Usted cumple los requisitos del programa MDCP. Usted no empezará a recibir los servicios hasta que haya acordado con el personal de su plan médico la fecha en que usted saldrá de la casa de reposo. Le pedimos que permanezca en la casa de reposo hasta que usted y su plan médico hayan acordado la fecha de su salida. Esto garantizará que sus servicios estén disponibles cuando usted salga de la casa de reposo. Usted recibirá otra notificación informándole cuándo comenzará a recibir los servicios del programa MDCP. Además, le enviaremos una notificación informándole del costo de su alojamiento, comida y copago.

N/AN/A
Room and Board and CopaymentN/AYou must pay room and board and copayment. You will pay them every month to your foster care home or assisted living facility. Your first month of room and board and copayment may be prorated based on your admission date to the facility. Your health plan will help you work with the facility on payments that are prorated. 

Debe pagar alojamiento, comida y copago. Deberá pagarlos cada mes al hogar de acogida o al centro de vida asistida en el que se encuentre. El pago del primer mes de alojamiento, comida y copago puede prorratearse en función de la fecha de ingreso en el centro. Su plan médico le ayudará a coordinar con el centro los pagos prorrateados.
N/AN/A

Note: PSU staff must enter Pending and Calculando in the Copayment fields on the English and Spanish versions of Form H2065-D, if the Medicaid for the Elderly and People with Disabilities (MEPD) specialist did not provide copayment amounts when Form H2065-D is generated. This applies to cases where an applicant or member has or will have a copayment.

PSU staff must enter the full R&B and copayment amounts for members admitting to an ALF or AFC on the first day of the month. PSU staff must enter the full R&B and copayment amounts for the first month of eligibility along with prorate and prorrateo if the member is admitting to an ALF or AFC on any other day of the month.

Members who receive Supplemental Security Income (SSI) and live in an ALF or AFC are not charged a copayment. PSU staff must enter $0 in the copayment amount fields for members who receive SSI.