1200, MCO Service Coordination

Revision 19-1; Effective June 3, 2019

Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. If a member receives long-term services and supports (LTSS), has a history of behavioral health issues or substance use disorders (SUD), or is dual eligible, the identified MCO service coordinator must contact the member at least once telephonically and at least once face-to-face per year. If the member receives STAR+PLUS Home and Community Based Services (HCBS) program, or has a complex medical condition, the identified MCO service coordinator must visit with the member face-to-face at least twice a year. If a member resides in a nursing facility (NF), the MCO service coordinator must meet with the member face-to-face at a minimum of four times per year.

All applicants or recipients of LTSS receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan (ISP) with the individual, family members and provider, as well as authorization of LTSS for the member. MCO service coordination is responsible for working with the member and his or her acute care and LTSS providers to ensure all of a member's medically and functionally necessary services are provided. This includes, but is not limited to, referring and assisting the member in obtaining appointments with specialists, participating in discharge planning for members in hospitals and/or NFs, referring members to community organizations for services, and assistance not covered by Medicaid. Service coordination requirements for members receiving STAR+PLUS HCBS program can be found in 3000, STAR+PLUS HCBS Program Eligibility and Services, 6000, Specific STAR+PLUS HCBS Program Services, 5000, Automation and Payment Issues in STAR+PLUS, and Appendices. Service coordination requirements for members receiving Medicaid state plan LTSS can be found in the Uniform Managed Care Contract.

The following sections detail MCO service coordinator responsibilities for members in certain facilities or programs.

1210 Service Coordinators and Nursing Facilities

Revision 19-1; Effective June 3, 2019

Members residing in a nursing facility (NF), (except members receiving hospice care or living outside the managed care organization (MCO) service area), must receive at least quarterly face-to-face visits for assessment purposes. NF staff should invite MCO service coordinators to their resident care planning meetings or other interdisciplinary team meetings, as long as the resident does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or telephonically. The MCO must maintain and make available upon request documentation verifying the occurrence of required face-to-face service coordination visits, which may coincide with or include participation in care planning or other interdisciplinary team meetings.

Service coordination activities for members residing in an NF include, but are not limited to:

  • Visiting members at least quarterly;
    • Assessing the member within 30 days of entry into an NF or enrollment into the health plan;
    • Visiting within 14 days of hearing that a significant change in condition of the member has occurred;
    • Visiting within 14 days of learning that a resident requests a transition to the community;
  • Developing a plan of care (POC) to transition the individual to the community (if appropriate and the resident’s choice);
    • If initial review doesn’t support return to the community, a second assessment will be conducted 90 days after the initial assessment;
  • Transitioning the member to the community in adherence with the Texas Promoting Independence Initiative, including Money Follows the Person (MFP), as appropriate;
    • Notifying the Relocation Contract specialist within three business days after meeting with the member;
    • Notifying the Local Authority for residents meeting Pre-Admission Screening and Resident Review (PASRR) requirements, Local Intellectual and Developmental Disability Authority (LIDDA) or Local Mental Health Authority (LMHA), as appropriate;
    • Working in conjunction with the NF discharge planning team;
    • Coordinating transition with community partners;
    • Coordinating transition if the resident is moving into a service area not served by this MCO, by setting up Single Case Agreements, as needed;
  • Identifying and addressing residents’ physical, mental or long term needs;
  • Assisting residents and families to understand benefits;
  • Ensuring access to and coordination of needed services;
  • Finding providers to address specific needs;
  • Coordinating and notifying of add-on services not included in the daily rate; and
  • Assistance with collection of applied income.
    • NF Business Office manager (BOM) is responsible for collecting applied income.
      • The BOM can notify the MCO service coordinator for assistance in collecting the applied income after two collection attempts are made with no success. The MCO service coordinator's role is to educate the resident and his or her responsible party on the rules regarding payment of applied income to the NF and the potential ramifications of not doing so.
    • If a member participating in the STAR+PLUS Home and Community Based Services (HCBS) program is admitted to an NF, the NF service coordinator must notify the Program Support Unit (PSU) within three business days of the admission using Form H2067-MC, Managed Care Programs Communication.

1220 MCO Service Coordinators and Programs Serving Members with Intellectual or Development Disabilities

Revision 19-1; Effective June 3, 2019

Individuals who have intellectual or developmental disabilities (IDD) and live in a community-based intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID) or who receive services through one of the following IDD waivers receive their acute care services only through the STAR+PLUS program and continue to receive their long-term services and supports (LTSS) through the 1915(c) Medicaid waivers:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); or
  • Texas Home Living (TxHmL).

Individuals who receive services through one of these four programs and receive Medicare Part B (dual eligible) are not included in the STAR+PLUS program.

Members with IDD that meet the above criteria have a named managed care organization (MCO) service coordinator. The number of required service coordination visits or telephone calls and level of service coordination varies by acuity and the member's or authorized representative's (AR's) personal preference.

These members also have a LIDDA provider that is a person(s) outside of the MCO who develops and implements an individual service plan (ISP) and monitors LTSS service delivery. The MCO service coordinator must respond to requests from the member's waiver case manager or service coordinator. The member's waiver case manager or service coordinator should invite MCO service coordinators to the care planning meetings or other interdisciplinary team meetings, as long as the member does not object. These meetings are not mandatory but are strongly recommended and participation may be in person or telephonically. The MCO service coordinator is responsible for the coordination of the member's acute care services.

1230 Service Coordinators and Home and Community Based Services - Adult Mental Health Program

Revision 19-1; Effective June 3, 2019

The Home and Community Based Services - Adult Mental Health (HCBS-AMH) program serves individuals who have severe and persistent mental illness (SPMI) and:

  • a history of extended (three cumulative or consecutive years of the past five years) institutional stays in psychiatric facilities;
  • SPMI and frequent visits to the emergency department; and
  • SPMI and frequent arrests and stays in a correctional facility.

HCBS-AMH provides an array of enhanced community-based services, including residential assistance, targeted to the program's population. HCBS-AMH is operated on a fee-for-service (FFS) basis through the Texas Health and Human Services Commission (HHSC). Each individual is assigned a recovery manager (RM), who monitors and coordinates HCBS-AMH services through recovery plan meetings. Members enrolled in HCBS-AMH receive their acute care services through their managed care organization (MCO) and their enhanced community-based services from providers contracted with HHSC. Additional information about HCBS-AMH can be found at Home and Community-Based Services — Adult Mental Health.

Program Point of Contact (PPOC)

  • Each MCO must have a designated PPOC for the AMH program. The PPOC is responsible for the following:
    • Ensuring MCO service coordinators are aware of HCBS-AMH services offered and their coordination responsibilities; and
    • Responding within three business days to concerns from HHSC or RMs to mitigate any issues with service coordination including uncooperative MCO service coordinators, missed teleconferences, or other concerns regarding MCO participation in the AMH program.

MCO Service Coordination Responsibility

  • MCO service coordination must participate in telephonic recovery plan meetings, as scheduled by HHSC or RMs, and provide any requested member-specific information prior to the meeting. MCO service coordinators must:
    • Send requested information to the HHSC or RM three business days prior to the scheduled recovery plan meeting. This information includes, but is not limited to the following:
      • updates regarding member condition;
      • sharing relevant authorizations, such as an authorization or provider contact information when an HCBS-AMH member receives Community First Choice (CFC) services;
      • upcoming MCO service coordinator face-to-face appointments and/or scheduled dates for telephonic contacts with the member; and
      • relevant member treatment documents as requested by the RM or HHSC.
    • Respond to ad-hoc requests from the RM or HHSC with "urgent" in the subject line within one business day.
    • Respond to non-urgent ad-hoc requests in a timely manner.
    • Coordinate with the Program Support Unit and RM or HHSC when a member transfers from STAR+PLUS Home and Community Based Services (HCBS) program to HCBS-AMH.

HCBS-AMH may provide transitional planning for individuals who reside in an institution and who are also enrolled in a STAR+PLUS MCO. MCO service coordinators must participate in planning meetings with an RM, telephonically or in-person, during the member's stay.  Planning meetings focus on coordination of services upon discharge from the inpatient psychiatric institution.  MCO service coordinators are responsible for providing the RM requested treatment information for transition planning purposes. STAR+PLUS MCOs must follow all discharge planning requirements as outlined in Uniform Managed Care Contract (UMCC), Section 8.3.2.5.

1240 MCO Service Coordinators and the Section 811 Project Rental Assistance Program

Revision 19-1; Effective June 3, 2019

The Section 811 Project Rental Assistance (PRA) program provides subsidized rental housing in coordination with supports to individuals with disabilities. Each tenant in the Section 811 PRA program has a “Section 811 service coordinator.” Managed care organization (MCO) service coordinators are the Section 811 service coordinators for STAR+PLUS members discharging from nursing facilities (NFs).

Provision of Services

Once an individual has occupied a Section 811 PRA housing unit, the MCO service coordinator must ensure STAR+PLUS Home and Community Based Services (HCBS) are in place so that the member will be successful in maintaining his or her tenancy. Continued participation in these services is voluntary and not a prerequisite for remaining in Section 811 PRA housing.

The Section 811 PRA program relies on Medicaid services and service coordination to provide the supports an individual needs to remain safely in the community. The MCO service coordinator is responsible for informing individuals in NFs about the availability of this program and if they are interested, to assist them in submitting an application and required documentation. The MCO may delegate this responsibility to the relocation specialist. If eligible, the MCO service coordinator must assist eligible individuals in accessing funding available to assist with relocations.

Communication between MCO and Texas Health and Human Services Commission (HHSC)

The MCO service coordinator must coordinate with the HHSC Section 811 Point of Contact (HHSC POC) on an ongoing basis regarding members participating in the Section 811 PRA program. The HHSC POC is listed on the Texas Department of Housing and Community Affairs (TDHCA) Section 811 PRA webpage: https://www.tdhca.state.tx.us/section-811-pra/contact.htm.

MCO Responsibilities – Helping Potential Applicants

Information on such laws and requirements will be conveyed at training provided by TDHCA and in the Texas Section 811 PRA Program Service Coordinator Manual. Specific responsibilities of the Section 811 service coordinator are listed below:

  • Assist in recruiting and pre-screening potential participants;
  • The MCO service coordinator or relocation specialist will assist individuals in accessing Section 811 PRA housing;
    • Inform NF residents who have indicated an interest in moving to the community about the availability of the Section 811 PRA program. Inform individuals who transitioned from an NF to the community within the past 12 months about the availability of the Section 811 PRA program;
    • Assist interested individuals in reviewing available properties and their leasing criteria on the TDHCA website (http://tdhca.state.tx.us/section-811-pra/participating-properties.htm);
    • Using information provided by TDHCA, inform interested individuals about the potential wait time for an available unit;
    • Assist interested individuals in completing an application for tenancy and compiling necessary documentation;
    • Ensure that all methods of outreach and referral are consistent with fair housing and civil rights, laws and regulations, and affirmative marketing requirements; and
  • Assist residents in maintaining their housing.

MCO Point of Contact Requirements – for Potential Applicants

For members who have applied to the Section 811 PRA program, the MCO must update information that was collected at the time of application to the program, if anything changes. This will ensure the member can be contacted and the information on file with TDHCA is accurate. The MCO must ensure the HHSC Section 811 POC and the TDHCA POC have the means to identify and contact the member within one business day of receiving a notice that a Section 811 PRA program unit is available.

MCO Responsibilities – for Existing Tenants

Once an individual has been accepted for tenancy in a Section 811 PRA program unit, the MCO service coordinator will provide the following support to assist individuals in maintaining their housing:

  • Subject to an individual's agreement to share this information, respond to any inquiry from the HHSC Section 811 POC relating to a member's participation in the Section 811 PRA program, including the services the member is receiving and who the service providers are;
  • Fulfill the obligations of the Section 811 service coordinator in the Conflict Management process set forth in the Texas Section 811 PRA Program Service Coordinator Manual, including:
    • Working with the Section 811 POC and the Section 811 PRA program property owner or the property owner's designated agent (such as the property management company) in the event there is an incident, including a lease violation which could jeopardize the individual's ability to maintain his or her tenancy in a Section 811 PRA program; and
    • Work with the Section 811 POC and the Section 811 PRA program owner or the owner's designated agent to support the member in such a way that they do not lose their housing as a result of a lack of services or a lack of coordination of services. As a tenant in a Section 811 PRA program unit, a member may refuse services and this does not place his or her housing at risk.

The MCO must ensure the HHSC POC and the TDHCA POC have the means to identify and contact an individual's Section 811 service coordinator within one business day of receiving notice of a concern from the Section PRA program owner, owner's designee, or TDHCA POC.

MCO Point of Contact Requirements – for Existing Tenants

MCO service coordinators serving members who are participating in the Section 811 PRA program must ensure that the HHSC POC has the MCO service coordinator’s contact information. If the MCO service coordinator information changes or is no longer fulfilling the roles and responsibilities associated with the Section 811 PRA program for a member, the MCO service coordinator must notify the HHSC POC.

Additional references for Section 811 Program Requirements for MCOs

MCO service coordinators serving members exiting an NF or other institution and who are participating in the Section 811 PRA program must comply with the roles and responsibilities assigned to them in the Inter-Agency Partnership Agreement (HHSC Contract No. 529-12-0134-00001), as amended and as applicable, and MCO service coordinators agree to fulfill the obligations assigned to Section 811 service coordinators in accordance with the Texas Section 811 PRA Program Service Coordinator Manual.

MCO service coordinators serving members who are participating in the Section 811 PRA program may download and read the Texas Section 811 PRA Program Service Coordinator Manual, available on TDHCA's webpage.

If requested by HHSC, the MCO service coordinator or designee must attend training on the Section 811 PRA program. Trainings can include, but are not limited to, in-person training, webinars, conference calls or responding to requests via email.

1250 Service Coordinators and the Medicaid for Breast and Cervical Cancer Program

Revision 19-1; Effective June 3, 2019

Individuals eligible for Medicaid through the Medicaid for Breast and Cervical Cancer (MBCC) program are a mandatory population in the STAR+PLUS program. The MBCC program provides Medicaid services including, but not limited to, the treatment of cancer and precancerous conditions for individuals with qualifying diagnoses between age 18 and their 65th birth month. An MBCC program member 18 to 20 years of age will be enrolled in STAR+PLUS. Eligibility for the MBCC program allows an individual under the age of 21 to participate in the STAR+PLUS program. Individuals in the MBCC program receive their Medicaid services through their STAR+PLUS managed care organization (MCO). The individual will be assigned a named service coordinator and receive at a minimum one telephonic contact and one face-to-face visit annually, unless otherwise requested by the MBCC member.

The MCO service coordinator assists the MBCC member with coordinating care. Coordination can include, but is not limited to, assistance with renewing Medicaid eligibility by reminding and assisting with paperwork. Continued participation in MBCC requires a completed MBCC renewal application and physician attestation the individual requires continued, active treatment for breast or cervical cancer or pre-cancer. The physician attestation and eligibility paperwork must be submitted every six months.

An MBCC individual under 21 can also be on the Medically Dependent Children Program (MDCP) interest list. If the individual reaches the top of the MDCP interest list, the individual can transfer from STAR+PLUS into MDCP since MDCP provides additional services not available in STAR+PLUS or the STAR+PLUS HCBS programs. Upon release from the MDCP interest list, the individual will be processed as a STAR member transitioning to MDCP.

When the individual reaches age 21, the MDCP member will transfer to STAR+PLUS HCBS program as a medical assistance only (MAO) upgrade using the high needs transition process.

MBCC members age 21 or older requesting STAR+PLUS HCBS program services can be upgraded to the STAR+PLUS HCBS program without going on the interest list. However, PSU staff must send an enrollment packet that includes Form H1200, Application for Assistance – Your Texas Benefits, as Medicaid for the Elderly and People with Disabilities (MEPD) is required to assess the Medicaid application using ME-Waiver eligibility rules.

After the enrollment packet is received, PSU staff will send Form H1200, along with Form H1746-A, MEPD Referral Cover Sheet, to MEPD. If the individual is eligible as an MAO applicant, MEPD will change the individual’s Medicaid from MBCC to ME-Waivers in the Texas Integrated Eligibility Redesign System (TIERS).