1100, Program Overview | Texas Health and Human Services

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Revision 19-1; Effective June 3, 2019

The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system to combine acute care with long-term services and supports (LTSS). The STAR+PLUS program does not change Medicaid eligibility or services. It does change the way Medicaid services are delivered.

The STAR+PLUS program combines acute care and LTSS, such as assisting in a member's home with activities of daily living (ADLs), home modifications, respite (short-term supervision) and personal assistance services (PAS). These services are delivered through providers contracted with managed care organizations (MCOs).

The STAR+PLUS program provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid members.

Service coordination, available to all members, is the main feature of the STAR+PLUS program. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members, and providers can work together to help members get acute care, LTSS, Medicare services for dually-eligible members and other community support services.

The STAR+PLUS Home and Community Based Services (HCBS) program is a program approved for the managed care delivery system, designed to allow individuals who qualify for nursing facility (NF) care to receive LTSS in order to be able to live in the community.

Elements of the STAR+PLUS system are different from traditional service delivery. See the Glossary for the definition of terms specific to the STAR+PLUS program. For a dictionary of acronyms used in the STAR+PLUS Program, refer to Appendix VII, Acronyms.

1110 Legal Basis

Revision 19-1; Effective June 3, 2019

Statutory basis for the STAR+PLUS program:

Texas Administrative Code (TAC) §353.601-607 and §353.1153; and
Government Code, Title 4, Executive Branch, Subtitle I, Health and Human Services, Chapter 533, Medicaid Managed Care Program.

1120 Values

Revision 19-1; Effective June 3, 2019

The principles and practices that form the foundation for the STAR+PLUS Home and Community Based Services (HCBS) program are based on the following values:

Members receive services based on their choices and ongoing assessment of their medical and functional needs.
The service delivery system is accessible to the member, responsive to his or her needs and preferences, and flexible in honoring choices regarding living arrangement, services and mode of service delivery.
Members use available family, community and third-party services and resources, as well as those provided through the STAR+PLUS HCBS program to meet their needs and identified goals.
Services provided to the member must provide safe, cost-effective, and medically or functionally necessary alternatives to nursing facility (NF) placement that allow the member the opportunity to use and maintain family and community contacts and services.
The individual service plan (ISP) reflects the member's active participation in the assessment and planning process and his or her responsibility to provide as much self-care as possible.
Services must support the member's efforts to retain or regain as much independence as possible in the activities of daily living (ADLs), living arrangement and other areas of personal choice, and in meeting any goals.
Individuals and members are provided the education, support and services needed to support the member's efforts to remain in or return to the community.
Within the constraints imposed by the cost limit on a member's ISP, the program promotes the member's active involvement and choices regarding the services provided.

1130 Service Model

Revision 18-2; Effective September 3, 2018

1131 Service Delivery Model

Revision 19-1; Effective June 3, 2019

Individuals enrolled in the STAR+PLUS program may select a service delivery model for personal assistance services (PAS) or Community First Choice (CFC) services identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H6516, Community First Choice Assessment, and Form H2060-A, Addendum to Form H2060. Individuals receiving STAR+PLUS Home and Community Based Services (HCBS) program services may reside alone, with family members or others at locations of their choice in the community, including adult foster care (AFC) homes or in licensed assisted living facilities (ALFs).

The STAR+PLUS HCBS program provides individuals with an array of services necessary to allow the individual to remain in or return to a community setting. Providers are contracted with managed care organizations (MCOs) to provide STAR+PLUS HCBS program services identified on the individual service plan (ISP). The MCO completes all initial and annual service planning activities, and verifies, authorizes, coordinates and monitors services. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists to determine financial eligibility for individuals not eligible for Supplemental Security Income (SSI). SSI eligible individuals are Medicaid eligible and can obtain STAR+PLUS HCBS program services without additional financial screening. (Refer to 3110 Medicaid, Medicare and Dual-Eligibles.)

STAR+PLUS members choose to participate in the agency option (AO), consumer-directed services (CDS) option or service responsibility option (SRO) delivery models.

Members who choose the AO work with the MCO to coordinate service delivery for each service in the ISP.
Members who choose the CDS model are given the authority to self-direct designated services. If the member chooses to self-direct designated services, the MCO coordinates delivery of non-member-directed designated services. In the CDS model, providers employed by the member or authorized representative (AR) must be qualified personnel to provide all authorized services when services are necessary. These personnel may be employed directly by or through personal service agreements or subcontracts with the providers. A member's services and service providers must be based on an MCO assessment of the member’s individual needs. More information is available in Appendix XXVIII, Consumer Directed Services (CDS) Training for Service Coordinators and CDS Training Manual.
In the SRO model, the provider is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The provider also orients attendants to provider policies and standards before sending them to members' homes. The member or designated representative (DR) is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant.

1132 Home and Community Based Services (HCBS) Settings

Revision 23-1; Effective March 1, 2023

The federal regulations at 42 Code of Federal Regulations (CFR) Section 441.301(c)(4) and Section 441.530, Home and Community Based Services (HCBS) Settings Rule, require settings where Medicaid HCBS are delivered. This includes services provided to members in the STAR+PLUS and STAR+PLUS HCBS program to have certain qualities as described below.

1132.1 Services and Settings Subject to HCBS Settings Rules Requirements

Revision 23-1; Effective March 1, 2023

The managed care organization (MCO) must ensure settings where the following STAR+PLUS services and STAR+PLUS Home and Community Based Services (HCBS) are delivered comply with requirements of the HCBS Settings Rule:

Community First Choice (CFC) personal assistance services
CFC Habilitation
Respite
Nursing
Physical therapy
Occupational therapy
Cognitive rehabilitation therapy
Speech therapy
Supported employment
Employment assistance
Support consultation
Assisted living
Adult foster care

1132.2 Requirements for HCBS Settings

Revision 23-1; Effective March 1, 2023

All Settings

A managed care organization (MCO) must ensure that the settings listed above have the following qualities as described in the Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(i-v) and Section 441.530(a)(1)(i-v):

The setting gives opportunities for members to seek employment and work in competitive, integrated settings.
The setting gives opportunities for members to engage in community life.
The setting provides opportunities for members to control personal resources.
The setting provides opportunities for members to receive services in the community.
The member selects the setting from among the setting options, including non-disability specific settings and an option for a private unit in a residential setting. The setting options are identified and documented in the person-centered service plan and are based on the individual’s needs and preferences.
The setting ensures the member’s rights of privacy, dignity and respect, and freedom from coercion and restraint.
The setting optimizes, but does not regiment, the member’s individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.
The setting facilitates member choice regarding services and supports, and who provides them.

Settings that are Provider-owned or Controlled

The Home and Community Based Services (HCBS) settings regulations include additional requirements for provider-owned or controlled residential settings. These requirements apply to assisted living facility (ALF) and adult foster care (AFC) settings:

The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the member. The member has at a minimum, the same responsibilities and protections from evictions that tenants have under the Texas Property Code.
Each member has privacy in their sleeping or living unit:
- units have entrance doors lockable by the member, with only appropriate staff having keys to doors;
- the member sharing units have a choice of roommates in that setting; and;
- the member has the freedom to furnish and decorate their sleeping or living units within the residential agreement.
The member has the freedom and support to control their own schedules and activities, and has access to food at any time.
The member is able to have visitors of their choosing at any time.
The setting is physically accessible to the member.

MCOs must ensure that any modifications to these requirements are supported by a specific assessed need and justified in the person-centered service plan. Include the following criteria in the plan:

a description of the specific and individualized assessed need that justifies the modification;
a description of the positive interventions and supports that were tried but did not work;
a description of less intrusive methods of meeting the need that were tried but did not work;
a description of the condition that is directly proportionate to the specific assessed need;
a description of routine collection and review of data to measure the ongoing effectiveness of the modification;
the established time limits for periodic reviews to determine if the modification is still necessary or can be stopped;
the member’s or legally authorized representative’s signature showing evidence of informed consent to the modification; and
the MCO service coordinator's assurance that the modification will cause no harm to the individual.

1133 Access to the Community

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services (HCBS) Settings Rule at 42 CFR Section 441.301(c)(4)(i) requires the member to have full access to the greater community. This includes opportunities to engage in community life, control personal resources, and receive services in the community in the same way a person not receiving Medicaid services.

The managed care organization (MCO) must ensure that providers not have policies or practices in place that restrict or obstruct the member’s access to the community. The MCO must also ensure provider service and support practices do not create an environment that is institutional in nature. The MCO must support the member’s desire to participate in the community.

The MCO must use the person-centered planning process to:

ensure the member has opportunities and supports needed to participate in their community when they want, both individually and in groups;
identify, develop, and make available information on transportation options for community access;
assist the member with developing meaningful relationships with other members of the community; and
ensure the member has services, resources, and supports to help them explore or maintain meaningful activities.

1134 Employment

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services (HCBS) Settings Rule at 42 CFR Section 441.301(c)(4)(i) requires the member have opportunities to seek employment and work in competitive integrated settings.

As part of the person-centered planning process, the managed care organization (MCO) must assess the member’s preferences and goals. This may include preferences and goals about seeking employment and working in competitive integrated settings. The MCO is responsible for assessing and providing information to the member about employment assistance and supported employment services available through STAR+PLUS HCBS (Uniform Managed Care Contract, Section 8.3.2.3, Service Coordinators).

1134.1 ALF and AFC Settings

Revision 23-1; Effective March 1, 2023

For the member living in assisted living facility (ALF) and adult foster care (AFC) settings, the managed care organization (MCO) must ensure the ALF and AFC providers support the member in achieving and maintaining their employment goals, as identified on the person-centered service plan.

For the member who is employed, the ALF or AFC is responsible for providing transportation or helping the member arrange transportation to and from their place of employment. The MCO must ensure that, for the member who wants to pursue opportunities for employment, the ALF or AFC provider encourages and, if needed, helps the member to contact their MCO service coordinator about STAR+PLUS Home and Community Based Services employment assistance and supported employment services.

MCOs should encourage ALF and AFC providers to develop internal policies and procedures related to:

providing information to the member about support and assistance the provider will offer related to pursuing employment; and
providing transportation to Medicaid recipients who are employed.

1135 Setting Choice

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(ii) and 42 CFR Section 441.530(a)(1)(ii) requires that the member is allowed to select a setting where services are delivered from setting options. Setting options must include non-disability specific settings.

The MCO service coordinator must facilitate the service planning process, including offering setting options that a member may choose. The MCO service coordinator must identify and document the setting options and selection, based on the member’s needs and preferences, in the member’s individual service plan (ISP).

For the member receiving assisted living facility (ALF) or adult foster care (AFC) services, the MCO service coordinator must, to the extent possible, provide the member with an opportunity to visit ALF and AFC settings to make an informed decision about where to live and receive services.

1136 Privacy, Dignity and Respect, and Freedom from Coercion and Restraint

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(iii) and 42 CFR Section 441.530(a)(1)(iii) requires that the setting ensures the individual’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

The managed care organization (MCO) must ensure the member is treated respectfully by providers and is free from coercion and restraint.

The member has the right to privacy, which includes having their information kept private and having personal care provided in private. The MCO must ensure providers respect and protect the member’s privacy.

The MCO must also ensure licensed and certified providers meet applicable licensing and certification requirements regarding privacy, dignity and respect, and freedom from coercion and restraint.

1137 Initiative, Autonomy and Independence

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(iv) require that a setting optimize but not regiment, the member’s initiative, autonomy, and independence in making life choices. This includes, but is not limited to, daily activities, physical environment, and with who they interact. The managed care organization (MCO) and providers must maximize the member’s ability to make choices while minimizing the risk of endangering the member or others.

The MCO must ensure providers support the member’s right to make choices about how they spend their time in any given setting and have opportunities to participate in community activities.

The MCO should coordinate with the member, legally authorized representative (LAR), other family members involved in service planning, and the provider to ensure:

the member is offered actual experiences to guide future choices;
the member’s daily activities have the appropriate balance between autonomy and safety;
the member’s personal preferences are prioritized over a guardian’s or provider’s preferences, unless a health and safety reason is documented; and
the member feels supported in working toward their goals and priorities.

The MCO ensures a provider does not:

force or coerce the member to participate in an activity when they do not wish to;
punish the member for not participating in an activity; or
make activity schedules without input from the members in the setting.

1138 Choice Regarding Services and Supports, and Who Provides Them

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(v) requires that the member has a choice about services and supports, and who provides them.

The managed care organization (MCO) ensures the member is free to choose who provides the services they receive and where they receive those services. The member must not be coerced or forced to get services in a particular setting. They may instead choose to go out into the community for the same services.

The service plan is the central place where the MCO should document and honor the member’s choices for services, supports and who provides them. The MCO ensures the person-centered planning process addresses the member’s needs. The MCO must inform the member that they can request a change to their person-centered service plan if they are not happy with their services. The MCO must require providers to help the member with contacting their MCO to discuss possible changes to their service plan if they are unhappy with their services.

1139 Requirements for ALF and AFC Providers

Revision 23-1; Effective March 1, 2023

1139.1 Residential Agreement

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services (HCBS) Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(A) requires that the unit where the member lives is a specific physical place. The place can be owned, rented or occupied under a legally enforceable agreement by the member, and the member has, at a minimum, the same responsibilities and protections from eviction that tenants have under the Texas Property Code.

The managed care organization (MCO) ensures an assisted living facility (ALF) or adult foster care (AFC) has a written, legally enforceable, residential agreement with the member that is a “lease” under Texas Property Code Chapter 92. It is subject to state law governing residential tenancies, including Texas Property Code Chapters 24, 91, and 92 and Texas Rules of Civil Procedure Rule 510.

The MCO must ensure that a residential agreement between an ALF or AFC and a member does not contain any provisions that contradict the HCBS Settings Rule.

The residential agreement must also include a provision that the member has the freedom to furnish and decorate their personal space, as required by 42 CFR Section 441.301(c)(4)(vi)(B)(3).

1139.2 Door Locks

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services (HCBS) Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(B)(1) requires that a member has privacy in their living unit or bedroom. This includes that the unit has an entrance door lockable by the member, with only appropriate staff having keys to doors as needed. Any modification to this requirement must be implemented per Section 1139.8, Modifications to HCBS Settings Rule Requirements.

The managed care organization (MCO) must ensure assisted living facility (ALF) and adult foster care (AFC) settings provide a lock on a member’s bedroom door that is lockable by the member. Alternative features designed for safety, such as doors on living units that are not lockable, or secure exits, may be used only when they are determined necessary based on a member’s individualized, assessed need and documented in the member’s person-centered plan.

The MCO must ensure that an ALF or AFC has policies and procedures for unlocking a resident’s door in an emergency.

The MCO, in collaboration with an ALF or AFC provider, must conduct regular and ongoing assessments to determine whether a door lock is appropriate for a member living in an ALF or AFC. Additionally, ALF and AFC providers may develop internal policies for door locks and related member assessments.

Note: HHSC clarifies that neither HHSC Long-term Care Regulation (LTCR) policies for ALF providers nor National Fire Protection Association (NFPA) Life Safety Code (including NFPA 101) conflict with the HCBS Settings Rule requirement that the member have a bedroom door lock. Bedroom door locks must meet all relevant specifications in HHSC LTCR policies and the Life Safety Code.

An ALF must comply with the applicable occupancy and general chapters in NFPA 101, Life Safety Code, including the requirements related to the type of lock that may be used on a door. HHSC LTCR Technical Memorandum 20-01 provides additional guidance to ALF providers on the type of locks that may be used.

NFPA only permits certain types of door locks. A door lock is acceptable as long as the door hardware unlocks all locks and opens with no more than one releasing operation. The locks cannot prevent the occupant(s) from leaving the bedroom or living unit. If the Medicaid recipient has a lock on their door, appropriate ALF or AFC staff must be able to unlock the door in an emergency. The staff may have a master key or special tool to unlock the door.

1139.3 Choice of Room and Roommate

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(B)(2) requires that the member has a choice of roommate(s) in the assisted living facility (ALF) or adult foster care (AFC).

The member must be informed during the provider selection process about the ALF or AFC’s roommate selection process and policies, including whether the setting offers private rooms. The managed care organization (MCO) must ensure an ALF or AFC provider offers the member a choice of roommate and provides information to the member about how to request a change of roommate.

Any modification to the member’s choice of roommate(s) must be implemented in accordance with Section 1139.8, Modifications to HCBS Settings Rule Requirements.

1139.4 Room Furnishings and Decorations

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(B)(3) requires that the member have the freedom to furnish and decorate their sleeping or living space. This requirement must be addressed in the member’s residential agreement with the assisted living facility or adult foster care provider.

Any modification to a Medicaid recipient’s right to furnish and decorate their living space must be implemented per Section 1139.8, Modifications to HCBS Settings Rule Requirements.

1139.5 Control of Daily Schedule and Access to Food

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services (HCBS) Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(C) requires that the member have the freedom and support to control their own schedules and activities and have access to food at any time.

As part of the person-centered planning process, the managed care organization (MCO) service coordinator must discuss with the member their goals and preferences, including those related to daily activities. The MCO must also ensure assisted living facility (ALF) and adult foster care (AFC) providers have processes in place to discuss with the member their preferences for their daily schedule and activities.

It is not permissible under the HCBS Settings Rule for an ALF or AFC to enforce a setting-wide curfew. The MCO must ensure an ALF or AFC provider permits the member to come and go from the setting as desired. The ALF or AFC providers may encourage or recommend, but not mandate, that the member return to the setting by a certain time.

An ALF or AFC must not include a requirement for the member to sign in and out with leaving the setting as a stipulation of its residential agreement with the member. An ALF or AFC may include sign in and out processes in its operating policies and procedures but must inform the member that the sign in and out process does not restrict the member’s ability to come and go from the setting.

The MCO must ensure the ALF or AFC provider allows the member to access food at any time. This includes allowing the member to have food or snacks before or after scheduled mealtimes. The ALF or AFC may leave the kitchen accessible to residents who would like to prepare a snack or small meal between regular meal time. They may also allow the member to keep their own food in their bedroom or another designated space, such as a pantry or cupboard, that they can access whenever they want.

Any modification to a Medicaid recipient’s right to control their daily schedule, including access to food at any time, must be implemented per Section 1139.8, Modifications to HCBS Settings Rule Requirements.

1139.6 Visitation

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(D) requires that a member must be able to have visitors of their choosing at any time.

The managed care organization (MCO) must ensure an assisted living facility (ALF) or adult foster care (AFC) allow the member to receive visitors at any time and provide a location where recipients can meet privately with their visitors. Limits on visitation due to COVID-19 are acceptable.

The MCO must ensure the ALF or AFC makes visitation policies available to the member and includes information about any potential restrictions to visitation such as requiring roommate consent for overnight visitors, requiring visitors to sign in, or prohibiting visitors who cause disturbances or pose a risk to any residents.

Any modification to the member having visitors at any time must be implemented per Section 1139.8, Modifications to HCBS Settings Rule Requirements.

1139.7 Physical Accessibility

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services (HCBS) Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(E) requires that the assisted living facility (ALF) or adult foster care (AFC) setting be physically accessible to the member.

The managed care organization (MCO) must ensure an ALF or AFC setting is physically accessible to the member.

An ALF’s compliance with this requirement may be demonstrated by confirming the ALF has a current license from the Texas Health and Human Services Commission (HHSC). This indicates that the setting meets the physical accessibility standards required by the Americans with Disabilities Act (ADA) and any other federal and state requirements for accessibility.

1139.8 Modifications to HCBS Settings Rule Requirements

Revision 23-1; Effective March 1, 2023

The Home and Community Based Services Settings Rule at 42 CFR Section 441.301(c)(4)(vi)(F) requires that any modifications to all the following conditions of the HCBS Settings Rule be supported by a specific need and justified in the member’s person-centered service plan:

The member has a legally enforceable agreement with the assisted living facility (ALF) or adult foster care (AFC) provider that provides the same responsibilities and protections from eviction that tenants have under the Texas Property Code.
The member’s sleeping or living unit has entrance doors lockable by the member, with only appropriate provider staff having keys to doors.
The member has a choice of roommates.
The member has the freedom to furnish and decorate their living space within the residential agreement.
The member has freedom and support to control their own schedules and activities, and has access to food at any time.
The member is able to have visitors of their choosing at any time.
The ALF or AFC setting is physically accessible to the member.

The managed care organization (MCO) ensures any modifications or restrictions to conditions one through six above are based on an individualized, assessed need and documented in the person-centered service plan. Document the following information in the person-centered service plan:

a description of the specific and individualized assessed need that justifies the modification;
a description of the positive interventions and supports that were tried but did not work;
a description of the less intrusive methods of meeting the need that were tried but did not work;
a description of the condition that is directly proportionate to the specific assessed need;
a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;
the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;
the member’s or legally authorized representative’s signature evidencing informed consent to the modification; and
the MCO service coordinator's assurance that the modification will cause no harm to the individual.

An MCO must ensure that condition number seven listed above is not modified.

1140 Program Services

Revision 18-2; Effective September 3, 2018

1141 Services Available Under STAR+PLUS

Revision 19-1; Effective June 3, 2019

If the service coordinator identifies a need, or the member requests additional services, the managed care organization (MCO) will assess the member and develop an appropriate individual service plan (ISP). Since MCOs are at risk for paying for a range of acute care and long-term services and supports (LTSS), there is an incentive to provide innovative, cost-effective care from the onset in order to prevent or delay the need for more costly institutionalization.

STAR+PLUS members who do not have Medicare are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals can choose a specialist to be their PCP and they receive all services, both acute care and LTSS, from the MCO.

Members who receive both Medicaid and Medicare (dual-eligible) choose an MCO, but not a PCP, because dual-eligible members receive acute care from their Medicare providers. The STAR+PLUS program does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid LTSS to dual-eligible members.

The STAR+PLUS program serves as an insurance policy if members have a need for LTSS at a future time. Refer to 3110, Medicaid, Medicare and Dual-Eligibles, for additional information on dual-eligible coverage.

Medicaid-only members (those who do not receive Medicare) receive traditional Medicaid acute care services plus an annual check-up. For these members, the cost of acute care services is included in the capitation payment to the MCO. For dual-eligible members, the MCO’s capitation payment does not include the cost of acute care.

1142 Long-term Services and Supports

Revision 17-5; Effective September 1, 2017

Day Activity and Health Services (DAHS) and Personal Attendant Services (PAS) are available to STAR+PLUS members who meet functional eligibility requirements. Community First Choice (CFC) services are available to STAR+PLUS members who meet an institutional level of care, meet functional eligibility requirements, and who receive Supplemental Security Income (SSI) or receive SSI-related Medicaid. Additional services are available under the STAR+PLUS Home and Community Based Services (HCBS) program. For a complete list of services provided under the STAR+PLUS program, refer to the managed care contracts governing the STAR+PLUS program at https://hhs.texas.gov/services/health/provider-information/managed-care-contracts-manuals.

1143 STAR+PLUS Services

Revision 17-1; Effective March 1, 2017

STAR+PLUS program members have access to medically and functionally necessary services available in the state plan. In addition, some members are eligible for additional services available in the STAR+PLUS Home and Community Based Services (HCBS) program services, in addition to their traditional state plan STAR+PLUS services. See:

1143.1, Services Available to STAR+PLUS Members; and
1143.2 , Services Available to STAR+PLUS Home and Community Based Services (HCBS) Program Members.

1143.1 Services Available to STAR+PLUS Members

Revision 19-1; Effective June 3, 2019

The Texas Health and Human Services Commission (HHSC) contracts with Medicaid managed care organizations (MCOs) for the provision of STAR+PLUS services. These Medicaid MCOs are responsible for providing a benefit package to members that includes all medically-necessary services covered under the traditional, fee-for-service (FFS) Medicaid programs, with the exception of non-capitated services provided to Medicaid members outside of the MCO capitation and listed in each managed care contract. (For example, Attachment B-1, Section 8.2.2.8, of the Uniform Managed Care Contract (UMCC).

STAR+PLUS members also receive enhanced benefits compared to the traditional FFS Medicaid coverage:

waiver of the three-prescription per month limit for members not covered by Medicare; and
waiver of spell illness limitation for members admitted to a facility as a result of their severe and persistent mental illness (SPMI).

Medicaid MCO contractors are responsible for providing a benefit package to members that includes an annual adult well check for members and prescription drugs. STAR+PLUS MCO contractors should refer to the current Texas Medicaid Provider Procedures Manual (TMPPM) and the Texas Medicaid Bulletin postings for a more inclusive listing of limitations and exclusions that apply to each Medicaid benefit category. (These documents can be accessed online at: www.tmhp.com.)

The services listed in the managed care contracts (for example, UMCC) are subject to modification based on federal and state laws and regulations and program policy updates.

1143.1.1 Services Included Under the MCO Capitation Payment

Revision 22-3; Effective August 3, 2022

Services included under the managed care organization (MCO) capitation payment include:

ambulance services;
audiology services, including hearing aids;
behavioral health services, including:
- inpatient mental health services;
- outpatient mental health services;
- outpatient chemical dependency services;
- mental health rehabilitation for non-duals;
- mental health targeted case management for non-duals;
- detoxification services;
- psychiatry services; and
- counseling services;
birthing services provided by a certified nurse midwife in a birthing center;
chiropractic services;
dialysis;
durable medical equipment (DME) and supplies;
emergency services;
family planning services;
home health care services for acute conditions;
hospital services;
laboratory;
long-term services and supports (LTSS) (Refer to 1143.1.2 below);
medical checkups and Comprehensive Care Program (CCP) services for Medicaid for Breast and Cervical Cancer (MBCC) members under age 21;
oncology services;
optometry, glasses and contact lenses, if medically necessary;
podiatry;
prenatal care;
prescription drugs;
primary care services;
preventive services including an annual adult well check;
radiology, imaging and X-rays;
specialty physician services;
therapies, including physical, occupational and speech for acute conditions;
transplantation of organs and tissues; and
vision services.

1143.1.2 Long-term Services and Support Listing

Revision 19-1; Effective June 3, 2019

The following is a non-exhaustive, high-level listing of long-term services (LTSS) and supports included under the STAR+PLUS program:

Community First Choice (CFC) – Available to all Medicaid-eligible members (with the exception of members who are considered medical assistance only (MAO)) who meet an institutional level of care (LOC) for a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related condition (ICF-IID), or psychiatric hospital (also called an institution for mental disease (IMD)). CFC services are provided in a community-based setting. Community-based settings do not include:
- Hospitals
- NFs
- IMDs
- ICF-IIDs
- Any setting with the characteristics of an institution
CFC services include:
- Personal assistance services (PAS), which provide assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks;
- Habilitation services, which provide acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks;
- Emergency response services (ERS), which are back-up systems and supports, including electronic devices with a backup support plan to ensure continuity of services and supports; and
- Support management, which is training provided to members or the authorized representatives (ARs) on how to manage and dismiss their attendants.
- Personal Assistance Services (PAS), formerly known as Primary Home Care (PHC) — All members may receive medically and functionally necessary PAS. PAS includes assisting the member with the performance of activities of daily living (ADL) and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the member's needs and the plan of care (POC). To be eligible for state plan PAS, the MCO must assess applicants in a face-to-face visit. Members are assessed using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide or Form H6516, Community First Choice Assessment. In order to be eligible for PAS through programs other than CFC or STAR+PLUS Home and Community Based Services (HCBS) program, members must score at least 24 on Form H2060.
- PAS includes three service delivery options:
  - Agency Option (AO);
  - Consumer Directed Services (CDS) Option; and
  - Service Responsibility Option (SRO).
Day Activity and Health Services (DAHS) — All members of a STAR+PLUS managed care organization (MCO) may receive medically and functionally necessary DAHS. DAHS includes nursing and personal assistance services, therapy extension services, nutrition services, transportation services and other supportive services (PAS). These services are provided at facilities licensed by the state.
STAR+PLUS HCBS program is for those members who qualify for such services — The state also provides an enriched array of services to members who would otherwise qualify for NF care through the STAR+PLUS HCBS program. The MCO must also provide medically necessary services that are available to members who meet the functional and financial eligibility for the STAR+PLUS HCBS program.
NFs — Institutional care to members whose physician has certified that the member has a medical condition that requires 24-hour nursing care that meets medical necessity (MN) requirements. The need for custodial care solely does not constitute MN for an NF placement. Institutional care includes coverage for the medical, social and psychological needs of each resident, including room and board, social services, medications not covered by Medicare Part B or D, medical supplies and equipment, rehabilitative services and personal needs items.

1143.1.3 STAR+PLUS Personal Assistance Services (PAS) Practitioner’s Statement of Need (PSON)

Revision 20-2; Effective October 1, 2020

State plan personal assistance services (PAS) must be authorized according to 42 Code of Federal Regulations (CFR) §440.167. STAR+PLUS managed care organizations (MCOs) must authorize state plan PAS either in the service plan developed and approved by the MCO for all STAR+PLUS members or by requiring a practitioner’s statement of need (PSON). Note: See Uniform Managed Care Contract Section 8.1.12.4, STAR+PLUS MRSA Contract Section 8.1.13.2 and STAR+PLUS Expansion Contract Section 8.1.13.2. All STAR+PLUS members are considered members with special health care needs.

If the MCO chooses to require a PSON, the PSON may be requested under one or more of the following circumstances:

at initial request;
if original approval was based on temporary need;
if the member experiences a significant change in condition, as defined by managed care contracts; or
at reassessment.

A PSON cannot be required for PAS provided under the STAR+PLUS Home and Community Based Services (HCBS) program or Community First Choice (CFC).

Implementing a PSON process should not cause a delay in a prior authorization decision or in delivery of PAS that has been assessed as medically or functionally necessary. The PSON request must be initiated 90 days prior to the expiration of the authorization for PAS, if required upon reassessment. For a significant change in condition, the PSON must be initiated during the 21-day follow-up period for reassessment. The MCO must have a documented process in place for the steps that they will take to follow up with the practitioner to secure the PSON. This process should include the steps that will be taken to notify the member and service provider of the status, including outreach attempts by phone, in writing or in person. The MCO must accept a PSON signature that was gathered by the member or the member’s service provider.

Authorization Extension and Outreach Efforts

Previously authorized services must continue until a signed PSON is obtained. The MCO must have a process in place to extend the authorization to ensure the member has no gap in services while additional outreach efforts are being made by the MCO. The extended authorization period may not exceed 45 additional days. During the extended authorization period, the MCO must continue outreach to the practitioner and to offer the member the opportunity to change to a new practitioner. The MCO must communicate to the member and the member’s service provider the potential impact to PAS services if a signed PSON is not obtained. The MCO must document in the member’s record all outreach efforts and member education related to the PSON.

Required Data Elements

If the STAR+PLUS MCO chooses to require a PSON for STAR+PLUS PAS, the MCO must develop their own version of a PSON. The PSON must include the following separate data elements:

Member name;
Member identification (ID) number;
Member date of birth (DOB);
Certification that the member was evaluated by a practitioner in the last 12 months;
If the practitioner certifies that they have evaluated the member in the last 12 months, additional certification that the member has a medical diagnosis resulting in one or more functional limitations, as indicated, or that the practitioner is unable to certify the member has a medical diagnosis resulting in one or more functional limitations;
Notation of whether the medical diagnosis is resulting in a temporary need, along with the expected end date;
All of the items listed in Parts III and IV on Form 3052, Practitioner's Statement of Medical Need;
Practitioner printed name;
Practitioner address;
Practitioner phone number;
Practitioner license number;
Signature of physician, nurse practitioner, advanced practice registered nurse or physician assistant; and
Date form was signed.

The MCO also must provide the practitioner a copy of the completed Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, when requested.

If the MCO has exhausted all efforts to obtain a PSON and intends to deny, limit, reduce, suspend, terminate or make any other adverse determination regarding a member’s services, the MCO must follow the procedures found in the Uniform Managed Care Manual, Chapter 3.21, Medicaid MCO’s Notices of Actions Required Critical Elements.

1143.2 Services Available to STAR+PLUS Home and Community Based Services Program Members

Revision 22-1; Effective March 1, 2022

Services necessary for the individual to remain in or return to the community are identified from the array of services available through the STAR+PLUS Home and Community Based Services (HCBS) program.

STAR+PLUS HCBS program services include:

Adaptive Aids and Medical Supplies, which encompasses medical equipment and supplies, including devices, controls or appliances specified in the plan of care (POC), that enable individuals to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live.
Adult Foster Care (AFC) is a 24-hour living arrangement for persons who, because of physical or mental limitations, are unable to continue residing in their own homes. Services may include meal preparation, housekeeping, personal care, help with ADL, supervision and the provision of or arrangement of transportation.
Assisted Living Facility (ALF) Services is a 24-hour living arrangement in licensed personal care facilities that provides personal care, home management, escort, social and recreational activities, 24-hour supervision, provision or arrangement of transportation, and supervision of, assistance with and direct administration of medications. Under the STAR+PLUS HCBS program, such facilities may contract to provide services in two distinct types of living arrangements:
- ALF apartments; or
- ALF non-apartment settings.
Cognitive Rehabilitation Therapy (CRT) is a service that assists an individual in learning or relearning cognitive skills, lost or altered as a result of damage to brain cells/chemistry, to enable the individual to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. CRT is provided in accordance with the POC developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
Dental Services are services provided by a dentist to preserve teeth and meet the medical need of the member. Allowable services include:
- emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection;
- preventative procedures required to prevent the imminent loss of teeth;
- the treatment of injuries to teeth or supporting structures;
- dentures and the cost of preparation and fitting; and
- routine procedures necessary to maintain good oral health.
Emergency Response Services (ERS) is an electronic monitoring system for use by functionally impaired individuals who live alone, are isolated in the community or are at high risk of institutionalization. In an emergency, the member can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-days-a-week capability, helps ensure that the appropriate persons or service provider respond to an alarm call from the member.
Employment Assistance Services (EAS) is a service that assists the member with locating competitive employment or self-employment.
Financial Management Services (FMS) is assistance to members with managing funds associated with services elected for the Consumer Directed Services (CDS) option and is provided by the financial management services agency (FMSA). This service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.
Home-Delivered Meals (HDM) is a service that provides nutritionally sound meals delivered to the member’s home.
Minor Home Modifications (MHMs) is a service that assesses the need for, arrange for and provide modifications or improvements to an individual's residence to enable the individual to reside in the community and to ensure safety, security and accessibility.
Nursing Services includes, but is not limited to, assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing, developing the health care plan and teaching individuals about proper health maintenance.
Occupational Therapy (OT) Services are interventions and procedures to promote or enhance safety and performance in instrumental activities of daily living (IADLs), education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed OT assistant under the direction of a licensed occupational therapist, within the scope of the therapist’s state licensure.
Personal Assistance Services (PAS) includes assisting the member with the performance of ADL and household chores necessary to maintain the home in a clean, sanitary and safe environment. The level of assistance provided is determined by the member’s needs and the POC. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing and protective supervision provided solely to ensure the health and welfare of a member with cognitive/memory impairment and/or physical weakness. To be eligible for STAR+PLUS HCBS program PAS, the MCO must assess applicants in a face-to-face visit. MCOs assess members using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment. STAR+PLUS HCBS program PAS eligibility only requires that the applicant or member needs assistance with at least one personal care task identified on Form H2060. The 24-point scoring eligibility for state plan PAS does not apply to STAR+PLUS HCBS program PAS.
Physical Therapy (PT) Services is specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. Services include the full range of activities provided by a physical therapist or a licensed PT assistant under the direction of a licensed physical therapist, within the scope of the therapist’s state licensure.
Respite Care Services provide temporary relief to persons caring for functionally impaired adults in community settings other than Adult Foster Care (AFC) homes or Assisted Living Facilities (ALF). Respite services are provided in-home and out-of-home and are limited to 30 days per individual service plan (ISP) year. Room and board is included in the payment for out-of-home settings.
Speech and/or Language Pathology Services is the evaluation and treatment of impairments, disorders or deficiencies related to a member’s speech and language. Services include the full range of activities provided by speech and language pathologists under the scope of their state licensure.
Supported Employment Services (SES) are services that assist the member with sustaining competitive employment or self-employment.
Transition Assistance Services (TAS) assists members with non-recurring set-up expenses for transitioning from nursing homes to the community. Services may include assistance with security deposits for leases on apartments or homes, essential household furnishings, set-up fees for utilities, moving expenses, pest eradication or one-time cleaning.