2200, Member Rights and Responsibilities

Revision 19-1; Effective June 3, 2019

Member rights and responsibilities are included in the Member Handbook. The required critical elements for member handbooks can be found in the Texas Medicaid and CHIP - Uniform Managed Care Manual.

The Member Handbook must be provided to the member at application. This document is shared in the language preference expressed by the applicant/member.

In addition, an applicant, member or AR may refer to the Title 1 Texas Administrative Code (TAC) Part 15 §353 Subchapter C, Member Bill of Rights and Responsibilities, to view the full list of member rights and responsibilities.

2210 Notifications

Revision 19-1; Effective June 3, 2019

2211 Program Support Unit Notification Requirements

Revision 23-2; Effective June 30, 2023

Program Support Unit (PSU) staff are responsible for preparing and sending notifications to the applicant, member or authorized representative (AR) advising of actions taken regarding program eligibility and the right to a fair hearing. Form H2065-D, Notification of Managed Care Program Services, is the legal notice sent to an applicant, member or AR of the actions taken regarding STAR+PLUS Home and Community Based Services (HCBS) program. Form H2065-D must be completed in plain language that can be understood by the applicant, member or AR. The language preference of the applicant, member or AR must be considered.

The applicant, member or AR must be notified on Form H2065-D within two business days of the date a case is certified. Form H2065-D also includes information on the individual's room and board charges and copayment, if applicable.

Form H2065-D is also used to notify an applicant who is denied program eligibility or a member whose program eligibility is denied or terminated. The PSU staff must notify the applicant, member or AR on Form H2065-D of the denial of application within two business days of the decision. Refer to 3630, Denial or Termination Procedures.

Depending on when the notification is generated, it will either be uploaded to the managed care organization’s (MCO’s) STAR+PLUS folder, following the instructions in 5110, MCOHub Naming Convention and File Maintenance, on the case action date.

2212 MCO Notification Requirements

Revision 19-1; Effective June 3, 2019

The managed care organization (MCO) is responsible for notifying the member or authorized representative (AR) when a service is either denied or reduced. This is considered an adverse action and the member or AR has a right to appeal. Appeal rights of STAR+PLUS members are in the Uniform Managed Care Manual (UMCM).

2220 Notifications with MEPD Involvement

Revision 19-1; Effective June 3, 2019

Some actions are based on decisions related to Medicaid financial eligibility determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialist. The Program Support Unit (PSU) staff must coordinate changes, approvals and denials of Home and Community Based Services (HCBS) program services with the MEPD specialist.

Although the MEPD specialist is required to notify the applicant, member or authorized representative (AR) of all Medicaid eligibility decisions, the PSU is required to send the STAR+PLUS HCBS program applicant, member or AR the notification of denial of STAR+PLUS HCBS program services on Form H2065-D, Notification of Managed Care Program Services.